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South Yorkshire and Bassetlaw - Commissioning for Outcomes Policy

FINAL

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Version Control

Version Date Author Changes

v1.0 01/04/2015 Dr Sarah Leverv1.1 19/06/2015 Hilary Porter Added wording specifically excluding

tonsillectomy as part of cancer treatment/management

V1.2 24/08/2015 Rebecca Chadburn

Change of email address

V2 28/07/16 Dr Sarah LeverRenamed Clinical thresholds policy with 7 additional clinical thresholds added. Changes to process for referral and approval for treatment. Prior approval only required when deemed exceptional

V3 Dr Sarah Lever Renamed South Yorkshire and Bassetlaw Commissioning for Value policy.Additional clinical thresholds added and commissioning policy made expressly clear for all procedures including, cosmetic, plastic and fertility procedures.

V8 4/9/17 Jack Harding FormattingV14V15 20/12/17 Jack Harding Includes updated links to IFR policies and ACS

websiteV16 13/02/2018 Adele Spence Includes previous omission regarding BMI for

Doncaster breast augmentationV17 16/02/18 Abigail Tebbs Includes changes for Sheffield position on

Orthopaedic and cataract proceduresV18 07/08/18 Debbie Stovin Indicates the elements where Sheffield have

opted outV19 16/11/18 Julie Shaw Includes changes to Cataracts policy and

checklist and the Varicose Veins checklist

This policy is hosted on the South Yorkshire and Bassetlaw Accountable Care System website and can be accessed at: https://www.healthandcaretogethersyb.co.uk/about-us/useful-documents

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https://www.healthandcaretogethersyb.co.uk/about-us/useful-documents

Contents1. Executive Summary…………………………………………………………………………………………………………….4

SECTION 1…………………………………………………………………………………………………………………………….…......4

2. Introduction……………………………………………………………………………………………………………….……….4

3. Decision Making and Prioritisation Approach……………………………………………………………….…….4

4. Priorities for Annual Resource Allocation…………………………………………………………………….……..5

5. Service Developments………………………………………………………………………………………………….……..6

6. Scope of Document…………………………………………………………………………………………………….……….6

SECTION 2………………………………………………………………………………………………………………………………………7

7. Procedures of Limited Clinical Value and Clinical Thresholds………………………………………..……..8

7.1. Process for Referral……………………………………………………………………………………………..…..9

8. Procedures not routinely commissioned………………………………………………………………………………9

8.1 Process for referral……………………………………………………………………………………..……..…..9

9. Prior approval for treatment outside of this policy……………………………………,,……………..…….…10

10. Exceptionality……………………………………………………………………………………………………………..…..…..10

11. Appeals……………………………………………………………………………………………………………………………..…11

12. Monitoring and Payment……………………………………………………………………………………….……………12

13. Review…………………………………………………………………………………………………………………….…………..12

SECTION 3…………………………………………………………………………………………………………………………………….13

14. List of Treatments and Services where low priority procedures/clinical thresholds apply… .13

15. Plastics and Fertility Procedures…………………………………………………………………………………………..4 1

16. Clinical Thresholds Checklists………………………………………………………………………………………….……5 2

17. Patient Information Sheet……………………………………………………………………………………………………7 8

18. OPSC Codes……………………………………………………………………………………………………….…………….….81

19. Definitions……………………………………………………………………………………………………………………………8 4

20. South Yorkshire and Bassetlaw Individual Funding Request Policies…………………………………..8 5

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1. Executive Summary

Now more than ever, it is important for the NHS to demonstrate that it is making the most effective use of public monies to maximise the health and wellbeing of the people of South Yorkshire and Bassetlaw (SY&B). We need to ensure that our resources are used wisely to maximise the impact of the services we commission to improve health, reduce health inequalities and ensure our population receives appropriate high quality evidence based clinical care.

We seek to ensure that our commissioning decisions are fully informed and based on the best evidence available and provide best value for money. To ensure that we fulfil these aims, SY&B Commissioners have agreed a regional wide Commissioning for Outcomes Policy. The Policy sets out our approach and governance arrangements to ensure that as far as possible, our decisions are robust, rational and justifiable.

Section 1

2. Introduction

The purpose of this Policy is to establish a system for transparent and coherent prioritisation for the commissioning of health and wellbeing services. It provides a framework for making decisions about relative priorities at a strategic and planning/commissioning level and facilitates rational and reasonable decisions about which services are commissioned in accordance with the SY&B Sustainability and Transformation Partnership.

The Policy applies to all commissioning decisions made by SY&B CCGs and should be applied when healthcare interventions can no longer be prioritised on the basis of clinical evidence, outcomes and value for money.

This policy links with our strategic plan and commissioning intentions available at the STP plan LINK

3. Decision Making and Prioritisation Approach

SY&B CCGs are required to make decisions about strategic and operational priorities for annual resource allocation. These may arise from:

business cases for investment in services value for money reviews performance monitoring of services or specific treatments where they no longer

provide evidenced clinical value, outcomes and best value for money or are a lower priority than services we need to fund within our affordability envelope (including proposal for new Individual Funding Request (IFR) policies)

Decisions required outside of our planning process on funding outside existing commissioned services and exceptionality for individual cases. This may apply in the following circumstances:

A new intervention is made available that is of significant importance A new treatment or service is made available that provides such

significant health or financial benefits A proposal is submitted by an external body that provides benefits

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http://www.smybndccgs.nhs.uk/what-we-do/stp

SY&B CCGs work together to agree a common approach where decisions are not specific to individual CCGs and their providers. As legal entities, decisions are required by individual CCGs prior to implementation at a SY&B level. Accordingly, the decision making approach within individual CCGs is set out in Figure 1

Figure 1 SY&B process for decision making

SY commissioners collate first draft

Proforma completed stating where the document had come

from and who has been consulted

in the process

Individual CCG Primary and Secondary care clinicians to

have face to face discussions to review proposed clinical guidelines/ policy change.

Feedback to SY commissioners

Comments on 1st Draft to be

reviewed by SY commissioners

2nd Draft Guidelines to be sent out to all parties within individual

CCG's for comment (2 weeks response). Feedback to CCG

Lead GP and communications to SY Commissioners

Agree final draft guidelines

Patient engagement - SY&B approach in

each CCGSeek approval from NHSE

Agree communications

Notification to NHS England where appropriate ie. new

threshold is being produced

Final draft to be sent to individual CCG's for

approval - Governing Body approaval - 6-8 weeks

Approved guidelines/policy change to be disseminatied to GP's, Practice Managers

& Practice Nurses Clinical Directors to disseminate to Trust

clinicians

No

agr

eem

ent

Escalate to Directors of commissioning

4. Priorities for Annual Resource Allocation

SY&B CCGs will prioritise existing resources, reconsider commissioned services that are not considered to be delivering the expected health benefit, and consider any new services or business cases to ensure that we are utilising our resources effectively. Local needs and national benchmarking information, where appropriate, will guide CCGs in this prioritisation of expenditure at a local level between commissioning programmes. The following criteria will be used for consideration:

Alignment with the SY&B Accountable Care System Alignment with the CCGs’ strategic objectives or national mandatory priorities Benefits and outcomes are identified and evidenced/measurable Compliance with any legal and clinical frameworks or guidance and procurement

processes Response to a need that has been assessed Clinical effectiveness, outcomes including assessment by NICE or other evidence-

based review Impact on health inequalities and protected characteristics Will improve patient safety and experience Accessibility to service users Affordability and value for money

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5. Service Developments

SY&B commission services in line with NICE Guidance. There is a contractual requirement for providers to treat in line with NICE guidance.

The CCGs will not introduce new drugs/technologies on an ad hoc basis through the mechanism of individual case funding. To do so risks inequity, since the treatment will not be offered openly and equally to all with equal need. There is also the risk that diversion of resources in this way will de-stabilise other areas of health care which have been identified as priorities by the CCGs.

The CCGs expect consideration of new drugs/technologies to take place within the established planning frameworks of the NHS. This will enable clear prioritisation against other calls for funding and the development of implementation plans which will allow access for all patients with equal need.

The CCGs have a default policy of not funding a treatment where no specific policy exists to approve funding for the treatment. If the CCGs or an individual CCG has not previously been asked to fund an intervention that has the potential to affect a number of patients, applications should be made by clinicians for the CCGs/CCG to consider the intervention through its general commissioning policy and not by way of an IFR application.

Interventional Procedure Guidance issued by NICE will be deemed by the CCGs as a Service Development and will not be routinely funded by the CCGs unless agreed in advance.

6. Scope of Document

SY&B Commissioning for Outcomes Policy covers the following:

Clinical thresholds across a range of procedures to ensure that when patients do receive treatment, they achieve the best possible outcomes (7.1)

Procedures which are not routinely commissioned and therefore require prior approval through the Individual Funding Request Panel (8.1)

The SY&B Commissioning Guidelines for Plastic Surgery Procedures have been incorporated into this document

The Y&H Fertility Policy has been incorporated into this document

This document sets out:

The procedures covered by this policy The referrals process including the use of the IFR process where prior approval is

required or there is a case for exceptionality The procedures and threshold for treatment Monitoring arrangements Rules around payment Referral checklists Patient information sheet

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SECTION 2

CLINICAL THRESHOLDS REFERRAL PROCESS

GP reviews individual case against Threshold Checklist

Receiving Clinician accepts patient for treatment

If threshold applies and GP deems patient suitable and fit

for referral

GP completes electronic checklist and sends with

referral letter

If patient meets threshold, continues to treatment

Receiving Clinician reviews case against threshold criteria

If patient does not meet threshold criteria but GP

considers patient may meet exceptionality policy

GP refers to Individual Funding Request Panel

Where IFR Panel approve procedure

GP refers with IFR approval

Where IFR panel approve procedure

If patient doe s not meet threshold criteria but

Receiving Clinician considers patient may meet

exceptionality policy

Receiving Clinician refers to IFR Panel

Patient treated

If patient does not meet criteria, refer back to GP

NB The GP should complete the electronic checklist to confirm that the patient meets the criteria The Receiving Clinician should confirm that the electronic checklist is present and that the patient meets the criteria Checklists should be retained by the Trust to allow the CCG to carry out compliance audits

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7. Procedures of Limited Clinical Value and Clinical Thresholds

The table below lists the procedures to which clinical thresholds apply and the responsibilities of the accepting and referring clinician

All threshold procedures require a referral checklist to accompany the referral where the criteria for treatment are met.

Table 1: Responsibilities of accepting and referring clinician in operation of the clinical thresholds policy

Procedure Referring clinician responsibility Accepting clinician responsibility

2Carpal Tunnel Complete the checklist and attach to referral letter

Check and electronically sign/accept the checklist

2Dupuytren’s Disease Complete the checklist and attach to referral letter


2Trigger Finger Complete the checklist and attach to referral letter


2Ganglion Complete the checklist and attach to referral letter


2Hip and Knee replacement Complete the checklist and attach to referral letter


Benign Skin Lesions Complete the checklist and attach to referral letter


Cholecystectomy Complete the checklist and attach to referral letter


Hernia Repair Complete the checklist and attach to referral letter


2Cataract Surgery Optometrist completes and signs checklistChecklist from GP not usually required


1Grommets Complete the checklist and attach to referral letter


1Tonsillectomy Complete the checklist and attach to referral letter


Hysterectomy for Heavy Menstrual Bleeding

Checklist from GP not required Complete and sign checklist

1Varicose Veins Surgery Complete the checklist and attach to referral letter


Male Circumcision Complete the checklist and attach to referral letter


Benign Perianal skin tags Complete the checklist and attach to referral letter


Haemorrhoidectomy Complete the checklist and attach to referral letter


Ingrowing Toe Nail Complete the checklist and attach to referral letter


Chalazion Complete the checklist and attach to referral letter


Blepharoplasty Complete the checklist and attach to referral letter


2Hallux Valgus Complete the checklist and attach to referral letter


2Arthroscopic Decompression of the shoulder

Complete the checklist and attach to referral letter


1 Checklist does not apply to Barnsley CCG

2 Procedure threshold does not apply to Sheffield CCG

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7.1 Making a Referral

Where a clinical threshold applies, GPs/optometrists/MSK service is required to complete the referral checklist, attaching the document with the referral. Referrals without a completed checklist should be returned to the referral source indicating the reason for rejection. The provider will confirm that the electronic checklist is present and that the patient meets the threshold, criteria. The secondary care element of the referral checklist will be completed (where this applies to a condition or procedure) and electronically signed/accepted by the receiving clinician to evidence that the patient meets the criteria. The document will be included within the patient notes.

A referral should only proceed to treatment if the patient meets the clinical threshold and a completed and compliant referral checklist is in place.

In some circumstances, GPs, Consultants or NHS clinicians may consider an individual has exceptional clinical circumstances and may benefit from a treatment which is not routinely provided. Requests for such treatments must be made through an Individual Funding Request (IFR) by the clinician. This request will then be considered, approved or rejected by an independent panel. The referral process is illustrated at Annex 1.

Note that a checklist is not required for heavy menstrual bleeding. Consultant to Consultant referrals must comply with the Consultant to Consultant Policy. In these circumstances the receiving Consultant must complete a checklist to indicate whether or not the patient meets the Threshold criteria. Any qualifying evidence must also be documented within the patient’s medical records.

The criteria for treatment and referral checklists for each procedure are set out in section 3 of this document.

Where patients do not meet the criteria for referral they should be advised to seek review by their GP or other appropriate health care professional should their condition change. Likewise where patients are on a pathway for elective care, clinical review should be available where necessary should a patient’s condition require earlier intervention.

Table 1 shows the responsibilities of the GP/Optometrist/Consultant for each condition.

8. Procedures not routinely commissioned

There are a number of services not routinely commissioned unless NICE Guidance applies. These include:

Vasectomy under General Anaesthetic Spinal Joint injections

(i) Therapeutic substance into spinal facet or sacroiliac joints(ii) Spinal injection as a diagnostic tool

Acupuncture (except for those conditions which are NICE approved)

8.1 Process for IFR Referral

If a GP or consultant feels that a patient’s circumstances are exceptional and may benefit from any of these treatments then they must be referred to the IFR Panel (10).

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The criteria for treatment and referral checklists for each procedure are set out in section 3 of this document.

9. Prior approval for treatment outside of this policy

Table 1 makes clear the requirements of the referring and accepting clinician for clinical threshold procedures. Clinicians will seek prior approval for treatment where patients are to be treated outside of these policies. Where a GP or Consultant believes that a patient might benefit from a procedure but where they do not meet the clinical threshold, the Clinician may apply to the IFR Panel to make the case for exceptionality. In these circumstances clinicians will be required to evidence the reasons for exceptionality. Where a procedure has a BMI restriction, patients whose high BMI is due to bulk muscle should be referred to the IFR panel as an exception.

10. Exceptionality

The CCG commissions according to the policy criteria. Requests for individual funding can be made only where exceptional circumstances exist and can be made through the NHS Individual Funding Request (IFR) procedure.

Responsibility for demonstrating exceptionality rests with the requesting clinician.

A patient may be considered exceptional to the general standard policy if both the following apply:

He/she is different to the general population of patients who would normally be refused the healthcare intervention, and

There are good grounds to believe that the patient is likely to gain significantly more benefit from the intervention than might be expected for the average patient with that particular condition.

In assessing exceptionality, the IFR panel will not consider social, demographic or employment circumstances.

Where a patient has already been established on a health care intervention, for example as part of a clinical trial or following payment for additional private care, this will be considered to neither advantage nor disadvantage the patient. However, response to an intervention will not be considered to be an exceptional factor.

The IFR policy for each CCG is shown here.

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Where prior approval is required it should be sought from the CCG in advance of the treatment being provided. All requests should be sent to:

Individual Funding Requests722 Prince of Wales Road,Sheffield, S9 4EU

or sent electronically to:

[email protected] (safehaven) or by safehaven fax to 0114 305 1370 adhering to confidentiality procedures. Only request by letter will be accepted. A clinical letter with a completed checklist (where relevant) should be sent to the IFR panel outlining why the patient does not meet the criteria and evidence supporting their exceptionality.

SC 29.26 of the contract makes clear that failure by the commissioner to respond within the agreed timescale may be taken as approval to treat. The IFR team aims to process requests through the panel within 13 days and request further information from the GP where required.

11. Appeals

SY&B CCGs recognise that there may be times when members of the public are dissatisfied with the decisions. We are committed to undertaking engagement and consultation work that, at a minimum meets national expectations of best practice, and believe that doing so will help ensure our decisions are in the interests of the public of SY&B.

Any patient/carer who feels that a decision is not justified may register a complaint or appeal, as per the below process. Ultimately, the CCGs’ decisions may be the subject to legal challenge from individuals or groups.

Figure 2- Patient Appeals Process

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mailto:[email protected]

Patient Appeals

CCG Complaints

Process*

Checklist Process

IFR Process

followed

IFR Appeal

Process

*Individual CCG complaints processes are detailed at the following Link

12. Monitoring and payment

CCGs will audit adherence to the clinical thresholds policy. Where there is no evidence that the patient meets the clinical threshold, CCGs will not pay for the patient’s treatment. SC 29.22 of the contract makes clear that the commissioner is under no obligation to pay for activity which has been undertaken by the provider in contravention of agreed prior approval schemes.

CCGs will monitor activity and finance levels on a monthly basis through the Contract Performance Meeting. A baseline will be established and activity monitored against the following OPCS codes listed in Table 2

13. Review

This policy will be reviewed on an annual basis.

Date of next Review: December 2018

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14. List of Treatments and Services where low priority procedures/clinical thresholds apply

Speciality Procedure Criteria for treatment Evidence Base Process Date of review

ENT Myringotomy/Grommets

The CCG will only fund grommet insertion in children (age under 18 for Barnsley/Doncaster/ Bassetlaw/Rotherham or 16 and under for Sheffield) when one or more of the following criteria are met:

Recurrent otitis media – 5 or more recorded episodes in preceding 12 month period

Suspected hearing loss at home or at school / nursery following 3 months of watchful waiting

Speech delay, poor educational progress due to hearing loss

Abnormal appearance of tympanic membrane

Persistent hearing loss for at least 3 months with hearing levels of:

25dBA or worse in both ears on pure tone audiometry OR

25dBA or worse or 35dHL or worse on free field audiometry testing AND

- Type B or C2 tympanometry

Suspected underlying sensorineural

ENT UK 2009 OME/Adenoid and Grommet Position Paperhttp://www.bapo.org.uk/tonsillectomy_position_papers_09.pdf

NICE guidelines – CG60 Surgical management of otitis media with effusion in children.https://www.nice.org.uk/guidance/cg60/chapter/1-Guidance

Perera R. Autoinflation for hearing loss associated with otitis media with effusion.(Cochrane review). In: Cochrane database of systemic reviews, 2006. Issue Chichester: Wiley Interscience.http://www.cochrane.org/CD006285/ENT_autoinflation-for-hearing-loss-associated-with-otitis-media-with-effusion-glue-ear

Evidence note. QIS. Number 22, January 2008. The clinical and cost effectiveness of surgical insertion of grommets for otitis media with effusion (glue ear) in children.file:///C:/Users/janet.sinclair-pinde/Downloads/EN22_Grommets.pdf

Clinical threshold – refer using checklist. IFR for exceptionalityBarnsley CCG require prior approval through IFR for this procedure

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http://www.cochrane.org/CD006285/ENT_autoinflation-for-hearing-loss-associated-with-otitis-media-with-effusion-glue-ear



https://www.nice.org.uk/guidance/cg60/chapter/1-Guidance


http://www.bapo.org.uk/tonsillectomy_position_papers_09.pdf

http://www.bapo.org.uk/tonsillectomy_position_papers_09.pdf


hearing loss

Atelectasis of the tympanic membrane where development of cholesteatoma or erosion of the ossicles is a risk

OME in the presence of a secondary disability e.g. autistic spectrum disorder, Down Syndrome, cleft palate

Persistent OME (more than 3 months) with fluctuating hearing but significant delay in speech, educational attainment or social skills.

Adults should meet at least one of the following criteria.

Persistent hearing loss for at least 3 months with hearing levels of 25dB or worse on pure tone audiometry or

Recurrent acute otitis media – 5 or more episodes in the preceding 12 month period or

Eustachian tube dysfunction causing pain or

Atelectasis of the tympanic membrane where development of cholesteatoma or erosion of the ossicles is a risk or

Atelectasis of the tympanic membrane where development of cholesteatoma or erosion of the ossicles is a risk or

Fickelstein Y. et al. Adult-onset otitis media with effusion. Archives of Otolaryngology -- Head & Neck Surgery, May 1994, vol./is. 120/5(517-27).Dempster J.H. et al. The management of otitis media with effusion in adults. Clinical Otolaryngology & Allied Sciences, June 1988, vol./is. 13/3(197-9)Yung M.W. et al. Adult-onset otitis media with effusion: results following ventilation tube insertion. Journal of Laryngology & Otology, November 2001, vol./is. 115/11(874-8).Wei W.I. et al. The efficacy of myringotomy and ventilation tube insertion in middle-ear effusions in patients with nasopharyngeal carcinoma. Laryngoscope, November 1987, vol./is. 97/11(1295-8)Ho W.K. et al. Otorrhea after grommet insertion for middle ear effusion in patients with nasopharyngeal carcinoma. American Journal of Otolaryngology, January 1999, vol./is. 20/1(12-5)Chen C.Y. et al. Failure of grommet insertion in post-irradiation otitis media with effusion. Annals of Otology,

Clinical threshold – refer using checklist. IFR for exceptionalityBarnsley CCG require prior approval through IFR for this procedure

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As a conduit for drug delivery direct to the middle ear

In the case of conditions e.g. nasopharyngeal carcinoma, ethmoidal cancer, maxillectomy, olfactory neuroblastoma, sinonasal cancer, and complications relating to its treatment (including radiotherapy), if judged that the risks outweigh the benefit by the responsible clinician.

Part of a more extensive procedure at Consultant’s discretion such as tympanoplasty, acute otitis media with facial palsy

Rhinology & Laryngology, August 2001, vol./is. 110/8(746-8)Ho W.K. et al. Randomized evaluation of the audiologic outcome of ventilation tube insertion for middle ear effusion in patients with nasopharyngeal carcinoma. Journal of Otolaryngology, October 2002, vol./is. 31/5(287-93)Park J.J. et al. Meniere's disease and middle ear pressure - vestibular function after transtympanic tube placement. ACTA OTOLARYNGOL, 2009 Dec; 129(12): 1408-13Sugaware K. et al. Insertion of tympanic ventilation tubes as a treating modality for patients with Meniere's disease: a short- and long-term follow-up study in seven cases. Auris, Nasus, Larynx, February 2003, vol./is. 30/1(25-8)Montandon P. et al. Prevention of vertigo in Meniere's syndrome by means of transtympanic ventilation tubes. Journal of Oto-Rhino-Laryngology & its Related Specialties, 1988, vol./is. 50/6(377-81)

ENT Tonsillectomy

The CCG will only fund tonsillectomy when one or more of the following criteria have been met:

Recurrent attacks of tonsillitis as defined by:

- Sore throats are due to acute tonsillitis which is disabling

Burton MJ, Glasziou PP. Tonsillectomy or adeno-tonsillectomy versus non-surgical treatment for chronic/recurrent acute tonsillitis. Cochrane Database of Systematic Reviews 1999, Issue 3. Art. No.: CD001802. First published online: July 26 1999. Available from:

Clinical threshold – refer using checklist. IFR for exceptionality

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and prevents normal functioning AND

- 7 or more well documented, clinically significant *, adequately treated episodes in the preceding year OR

- 5 or more such episodes in each of the preceding 2 years OR

- 3 or more such episodes in each of the preceding 3 years

Two or more episodes of Quinsy (peritonsillar abscess)

Severe halitosis secondary to tonsillar crypt debris

Failure to thrive secondary to difficulty swallowing caused by enlarged tonsils

Sleep disordered breathing or obstructive sleep apnoea diagnosed by an overnight pulse oximetry or polysonography

Biopsy/removal of lesion on tonsil

* A Clinically significant episode is characterised by at least one of the following:

o Oral temperature of at least 38.30C requiring antibiotic treatment

o Tender anterior cervical lymph nodes.

o Tonsillar exudates.

http://www.cochrane.org/reviews/en/ab001802.html (accessed 2016) Paradise JL, Bluestone CD, Bachman RZ. Efficacy of tonsillectomy for recurrent throat infection in severely affected children. Results of parallel randomized and non-randomized clinical trials. N England J Med 1984:310(11):674-83

SIGN. Management of sore throat and indications for tonsillectomy. A National clinical Guideline. April 2010http://www.sign.ac.uk/pdf/sign117.pdf (accessed 2016)

Barnsley CCG require prior approval through IFR for this procedure

Vascular Varicose The CCG will only fund Varicose Vein surgery if National Institute for Health and Care Clinical Dec 2018

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http://www.sign.ac.uk/pdf/sign117.pdf

http://www.cochrane.org/reviews/en/ab001802.html

http://www.cochrane.org/reviews/en/ab001802.html


Surgery Veins the patient meets the following criteria: BMI < 30 AND Intractable ulceration secondary to

venous stasis. OR Bleeding varicose vein or if the patient is

at high risk of re-bleeding. (i.e. there has been more than one episode of minor haemorrhage or one episode of significant haemorrhage from a ruptured superficial varicosity.) OR

Significant and or progressive lower limb skin changes such as Varicose eczema, or lipodermatosclerosis with moderate to severe oedema proven to be caused by chronic venous insufficiency (itching is insufficient for referral). OR

Recurrent thrombophlebitis (more than 2 episodes) associated with severe and persistent pain requiring analgesia and affecting activities of daily living and or instrumental activities of daily living*. OR

If the patient is severely symptomatic affecting activities of daily living and or instrumental activities of daily living. - ALL below must apply:

Symptoms must be caused by varicosity and cannot be attributed to any other co-morbidities or other disease affecting the lower limb.

There must be a documented unsuccessful six month trial of conservative management.**

Excellence (NICE). 2013. Varicose veins in the legs: the diagnosis and management of varicose veins. CG168. London: National Institute for Health and Care Excellence.

https://pathways.nice.org.uk/pathways/varicose-veins-in-the-

legs#content=view-node%3Anodes-information

(Accessed 2017)

Foti D & Kanazawa L. Activities of daily living. In: Pendleton H & Shultz-Krohn (eds) Pedretti’s Occupational Therapy: Practice Skills for Physical Dysfunction. 7th edition. United states. Elsevier Mosby; 2008 p157-159.NHS England Interim Clinical Commissioning Policy for Varicose Veins November 2013https://www.england.nhs.uk/commissioning/wpcontent/uploads/sites/12/2013/11/N-SC035.pdf

threshold – refer using checklist. IFR for exceptionalityBarnsley CCG require prior approval through IFR for this procedure

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https://www.england.nhs.uk/commissioning/wpcontent/uploads/sites/12/2013/11/N-SC035.pdf



https://pathways.nice.org.uk/pathways/varicose-veins-in-the-legs%23content=view-node%3Anodes-information%20




Evidence that symptoms are affecting activities of daily living and or Instrumental activities of daily living.

In the opinion of a vascular specialist, these symptoms can be reversed or significantly improved with treatment.

* Activities of daily living include: functional mobility, eating, bathing and personal care. They can be measured using the Barthel activities of daily living index. Instrumental activities of daily living include more complex tasks such as care of others, community mobility, health management and meal preparation.

** Conservative management should include advice on walking and exercise, avoidance of activities that exacerbate symptoms, leg elevation whenever sitting and weight loss if appropriate. Compression stockings should only be used where interventional treatment is unsuitable or the patient fails to meet the criteria

Dermatology Benign Skin lesions

The CCG will only offer funding if one or more of the eligibility criteria has been met.

Diagnostic uncertainty exists and there is suspicion of malignancy. GPs are reminded to refer to the 7 features suspicious of malignancy, as per NICE guidance on skin cancer*

The lesion is painful or impairs function and warrants removal, but it would be

http://www.nice.org.uk/nicemedia/live/10968/29814/29814.pdf (p35)

Kerr OA, Tidman MJ, Walker JJ et al. The profile of dermatological problems in primary care. Clin Exp Dermatol. 2010; (4):380-3

http://www.patient.co.uk/doctor/minor-surgery-in-primary-care


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unsafe to do so in primary care/community setting, for example because of large size (>10mm), location (e.g. face or breast) or bleeding risk. Removal would not be purely cosmetic.

Viral warts in the immunosuppressed. Patient scores >20 in Dermatology Life

Quality Index administered during a consultation with the GP or other healthcare professional.

*NICE recommend GPs use the following checklist, with major features scoring 2 and minor features scoring 1. A score of 3 indicated high suspicion of malignancy. If there is a strong clinical suspicion, the patient may be referred on the basis of one feature alone.

Major features Minor features Change in size Diameter > 7mm

Irregular in shape Inflammation Irregular in colour Oozing

Change in sensation

George S, Pockney P, Primrose J et al. A prospective randomised comparison of minor surgery in primary and secondary care. The MiSTIC trial. Health Technology Assessment 2008;12(23):iiiiv, ix-38.

Mazzotti E, Barbaranelli C, Picardi A et al. Psychometric properties of the Dermatology Life Quality Index (DLQI) in 900 Italian patients with psoriasis.Acta Derm Venereol 2005;85(5):409-13

http://www.dermatology.org.uk/quality/dlqi/quality-dlqi.html

Gynaecology Hysteroscopy and Hysterectomy formenorrhagia

Hysteroscopy for HMB will only be funded if one of the following criteria is met:

Trans vaginal ultrasound scan provided inconclusive results.Trans vaginal ultrasound scan was suggestive of an endometrial pathology (e.g. polyp or submucous fibroid).As part of an ablative procedure.Inter-menstrual bleeding over the age of 40yrs

https://www.nice.org.uk/guidance/cg44/chapter/1-Guidance (accessed 2016)https://www.rcog.org.uk/globalassets/documents/guidelines/research--audit/advice-for-hmb-services-booklet.pdf (accessed 2016)http://www.patient.co.uk/doctor/intrauterine-system-pro (accessed 2016)

Clinical threshold – refer using checklist. IFR for exceptionalityThe hysteroscopy element of

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http://www.patient.co.uk/doctor/intrauterine-system-pro

http://www.patient.co.uk/doctor/intrauterine-system-pro

https://www.rcog.org.uk/globalassets/documents/guidelines/research--audit/advice-for-hmb-services-booklet.pdf








Scan suggests thickened and cystic appearance/hyperplasia

Funding will not be provided for dilatation and curettage (D & C) as a standalone diagnostic or a therapeutic tool in the management of HMB.

Hysterectomy for HMB will only be funded if all the following criteria are met:

A levonorgestrel intrauterine system or LNG-IUS (e.g. Mirena) has been trialled for at least 6 months (unless contraindicated) and has not successfully relieved symptoms.A trial of at least 3 months each of two other pharmaceutical treatment options has not effectively relieved symptoms (or is contraindicated, or not tolerated). These treatment options include:NSAIDs e.g. mefenamic acidTranexamic acidCombined oral contraceptive pillOral and injected progestogens

Surgical treatments such as endometrial ablation, thermal balloon ablation, microwave endometrial ablation or uterine artery embolisation (UAE) have either been ineffective or are not appropriate,

Lethaby AE, Cooke I, Rees M. Progesterone/progestogen releasing intrauterine systems for heavy menstrual bleeding. (Cochrane Review). In: Cochrane Database of Systematic Reviews 2005; Issue 4Stewart A, Cummins C, Gold L, et al. The effectiveness of the levonorgestrelreleasing intrauterine system in menorrhagia: a systematic review. BJOG: an International Journal of Obstetrics and Gynaecology 2001;108(1):74–86.Hurskainen R, Teperi J, Rissanen P, et al; Quality of life and cost-effectiveness of levonorgestrel releasing intrauterine system versus Hysterectomy for treatment of menorrhagia: a randomised trial. Lancet. 2001;357(9252):273-7.Marjoribanks J, Lethaby A, Farquhar C; Surgery versus medical therapy for heavy menstrual bleeding. Cochrane Database Syst Rev. 2006;(2):CD003855http://www.nice.org.uk/nicemedia/live/11002/30401/30401.pdf - table 8.1, pg 56

this Threshold does not apply to Doncaster CCG. Normal referral process applies

General Surgery

Cholesystectomy

The CCG will only support the funding of cholecystectomy in mild or asymptomatic

Sanders G, Kingsnorth AN. Gallstones. BMJ. 2007;335:295-9.

Clinical threshold –

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gallstones if one or more of the following criteria are met:

High risk of gall bladder cancer, e.g. *gall bladder polyps ≥1cm, porcelain gall bladder, strong family history (parent, child or sibling with gallbladder cancer). (*Annual USS for smaller asymptomatic polyps)

Transplant recipient (pre or post transplant).Diagnosis of chronic haemolytic syndrome by a secondary care specialist.Increased risk of complications from gallstones, e.g. presence of stones in the common bile duct, stones smaller than 3mm with a patent cystic duct, presence of multiple stones.Acalculus cholecystitis diagnosed by a secondary care specialist.

Exclusion Criteria:

The CCG will not support the funding of cholecystectomy for patients in the following scenarios:

Patients with gallstones who experience one episode of mild abdominal pain only which can safely be managed with oral analgesia in primary care/community setting. Such patients should be advised to follow a low fat diet and only require referral if they have further episodes, OR their pain is not controlled by oral analgesia OR is associated with other

Sakorafas GH, Milingos D, Peros G. Asymptomatic cholelithiasis: is cholecystectomy really needed? A critical reappraisal 15 years after the introduction of laparoscopic cholecystectomy. Dig Dis Sci. 2007;52:1313-25.

http://www.rcseng.ac.uk/healthcare-bodies/docs/published-guides/gallstones (Accessed 2016) Behari A and Kapoor VK. Asymptomatic Gallstones (AsGS) – To Treat or Not to? Indian J Surg. 2012;74: 4–12.

Tsirline VB, Keilani ZM, El Djouzi S et al. How frequently and when do patients undergo cholecystectomy after bariatric surgery? Surg Obes Relat Dis 2013;1550-7289(13)00335-3.

Taylor J, Leitman IM, Horowitz M. Is routine cholecystectomy necessary at the time of Roux-en-Y gastric bypass? Obes Surg. 2006;16:759-61.

Caruana JA, McCabe MN, Smith AD et al. Incidence of symptomatic gallstones after gastric bypass: is prophylactic treatment really necessary? Surg Obes Relat Dis. 2005;1(6):564-7; discussion

refer using checklist. IFR for exceptionalityThe threshold in respect of mild (one episode of mild abdominal pain) does not apply to Doncaster, Bassetlaw or Sheffield CCG

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http://www.rcseng.ac.uk/healthcare-bodies/docs/published-guides/gallstones




symptoms, i.e. vomitingAsymptomatic gallstones in patients with diabetes mellitus. Asymptomatic gallstones in patients undergoing bariatric surgery, unless intra-operatively the gall bladder is found to be abnormal or the presence of calculi are very apparent. In such cases it is worth considering concurrent cholecystectomy.All patients with asymptomatic gallstones who do not meet any of the above criteria

567-8.

General Surgery

Hernia Repair (Ingiunal, femoral, Umbilical, para-umbilical, incisional)

Inguinal:Surgical treatment should only be offered when one of the following criteria is met:

Symptomatic i.e. symptoms are such that they interfere with work or activities of daily living ORThe hernia is difficult or impossible to reduce, ORInguino-scrotal hernia, ORThe hernia increases in size month on monthFemoral:All suspected femoral hernias should be referred to secondary care due to the increased risk of incarceration/strangulation

Umbilical/Paraumbilical and midline ventral hernias:Surgical treatment should only be offered when one of the following criteria is met:

pain/discomfort interfering with Activities of Daily Living OR

National Institute for Health and Care Excellence (2004) laprascopic surgery for hernia repair. [TA83]. London: National Institute for Health and Care Excellence. https://www.nice.org.uk/guidance/ta83 (Accessed 2016)

Medscape: Hernias. Available from: http://emedicine.medscape.com/article/775630-overview#a0104 (accessed 2016)McIntosh A. Hutchinson A. Roberts A & Withers, H. Evidence-based management of groin hernia in primary care—a systematic review. Family Practice, 2000;17(5), 442-447.GP notebook: Paraumbilical hernias. Available from: http://www.gpnotebook.co.uk/simplepage.cfm?ID=-1811546097&linkID=17862&cook=n


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http://www.gpnotebook.co.uk/simplepage.cfm?ID=-1811546097&linkID=17862&cook=n



http://emedicine.medscape.com/article/775630-overview#a0104

http://emedicine.medscape.com/article/775630-overview#a0104

https://www.nice.org.uk/guidance/ta83


Increase in size month on month ORto avoid incarceration or strangulation of bowel where hernia is > 2cm

Incisional:Surgical treatment should only be offered when of the following criteria are met:

Pain/discomfort interfering with Activities of Daily Living

(accessed 2016)

Friedrich M. Müller Riemenschneider F. Roll S. Kulp W. Vauth C. Greiner W & von der Schulenburg JM. Health Technology Assessment of laparoscopic compared to conventional surgery with and without mesh for incisional hernia repair regarding safety, efficacy and cost-effectiveness. GMS health technology assessment. 2008;4.

Dabbas. Frequency of abdominal wall hernias: is classical teaching out of date. JRSM Short Reports: 2011;2/5.

Fitzgibbons. Watchful waiting versus repair of inguial hernia in minimally symptomatic men, a randomised controlled trial. JAMA: 2006;295, 285-292

Purkayastha S. Chow A, Anthanasiou T, Tekkis P P & Darzi A. Ingunal hernias. Clinical evidence, 2008;0412, 1462-3846

Rosenberg J. Bisgaard T. Kehlet H. Wara P. Asmussen T. Juul P & Bay-Nielsen M. Danish Hernia Database recommendations for the management of inguinal and femoral hernia in adults.

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Dan Med Bull, 2011;58(2), C4243.

Simons M P. Aufenacker T. Bay-Nielsen M. Bouillot J L. Campanelli G. Conze J & Miserez, M. European Hernia Society guidelines on the treatment of inguinal hernia in adult patients. Hernia, 2009;13(4),343-403.

Primatesta P & Goldacre MJ. Inguinal hernia repair: incidence of elective and emergency surgery, readmission and mortality. International journal of epidemiology, 1996;25(4), 835-839.

Patient Care Committee, & Society for Surgery of the Alimentary Tract. Surgical repair of incisional hernias. SSAT patient care guidelines. Journal of gastrointestinal surgery: official journal of the Society for Surgery of the Alimentary Tract. 2004;8(3), 369.

The Society for Surgery of the Alimentary Tract. Surgical Repair of Groin Hernias. Available from: http://www.ssat.com/cgi-bin/hernia6.cgi (accessed 2016)

Orthopaedics Hip/Knee Replacement for osteoarthritis

The CCG will only fund hip/knee replacement for osteoarthritis when conservative measures have failed (listed below) or its successor AND the following criteria have been met:

http://pathways.nice.org.uk/pathways/musculoskeletal-conditions (accessed 2016)

National Institute of Health. Consensus

Clinical threshold – refer using checklist. IFR for

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http://pathways.nice.org.uk/pathways/musculoskeletal-conditions%20

http://pathways.nice.org.uk/pathways/musculoskeletal-conditions%20

http://www.ssat.com/cgi-bin/hernia6.cgi%20


Patient’s clinical condition must be clearly documented during a clinical encounter prior to surgical decision and documentation must include dates and description of measures:(If more than one joint replacement is being considered EACH surgery requires evaluation against the criteria set forth on its own merits. Of particular note if a patient has completed a joint replacement and another joint replacement is being considered, a complete re-evaluation of their condition for functional limitations and pain will be required. Patients DO NOT require referral back to the GP for re referral )Referral to the Hip or Knee Pathway ANDPatient has a BMI of less than 35 (Patients with BMI>35 should be referred for weight management interventions and upon 6 months of documented weight loss attempt with dates and intervention types- if the patient fails to lose weight to a BMI less than 35 then may consider referral through the IFR process.) ANDIntense to severe persistent pain (defined in table one and documentation to support is required) which leads to severe functional limitations (defined in table two and documentation to support is required), ORModerate to severe functional limitation (defined in table two and documentation to support is required) affecting the patients quality of life despite 6 months of conservative measures including referral to the local hip pathway or its successor.

development program. Dec 2003https://consensus.nih.gov/2003/2003totalkneereplacement117html.htm (accessed 2016)The musculoskeletal services framework – A joint responsibility: doing it differently. Department of Health. 2006.http://webarchive.nationalarchives.gov.uk/20130107105354/http:/www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4138412.pdf

Namba, R., Paxton, L., Fithian, D., and Stone, M. Obesity and perioperative morbidity in total hip and total knee arthroplasty patients. J Arthroplasty 20(7) Supplement 3 (2005), 46-50.

Hawkeswood MD, J.,Reebye MD, R. Evidence-based guidelines for the nonpharmacological treatment of osteoarthritis of the hip and knee. Issue: BCMJ, Vol. 52, No. 8, October 2010, page(s) 399-403 Articles.

College of General Practitioners. ‘Guideline for the non-surgical management of hip and knee osteoarthritis. July 2009.InterQualR. Total Joint Replacement Hip

exceptionality

The threshold for this procedure does not apply to Sheffield CCG – referrals should be made to the MSK service as usual

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http://webarchive.nationalarchives.gov.uk/20130107105354/http:/www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4138412.pdf



https://consensus.nih.gov/2003/2003totalkneereplacement117html.htm




Exceptions include:

Patients whose pain is so severe and/or mobility is compromised that they are in immediate danger of losing their independence and that joint replacement would relieve this.Patients in whom the destruction of their joint is of such severity that delaying surgical correction would increase the technical difficulties of the procedure.Rapid onset of severe hip pain

*Conservative measures:Patient education such as elimination of damaging influence on hips/knees, activity modification (avoid impact and excessive exercise), good shock-absorbing shoes and lifestyle adjustment. Documentation of this is required. ANDPhysiotherapy ANDOral NSAIDS a minimum of 3 weeks and paracetamol based analgesics (COX-2 Inhibitor of NSAIDS). Documentation of dates and medication types is required.

Procedures criteria. 2013.

NICE. TA44 Metal on Metal Hip Resurfacing. 04 January 2013.https://www.nice.org.uk/guidance/TA2/documents/appendix-b-proposal-paper-presented-to-the-institutes-guidance-executive2NHS England. Interim Clinical Commissioning Policy: Hip Resurfacing. November 2013https://www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2013/11/N-SC019.pdfKandala NB, Connock M, Pulikottil-Jacob R, Sutcliffe P, Crowther MJ, Grove A,Mistry H Clarke A. Setting benchmark revision rates for total hip replacement: analysis of registry evidence. BMJ 2015;350:h756 doi: 10.1136/bmj.h756 (Published 9 March 2015)

Orthopaedics Carpal Tunnel Syndrome

The CCG will only fund Carpal Tunnel Surgery when either of the following criteria is met:

Severe symptoms at presentation (including sensory blunting, muscle wasting, weakness on thenar abduction or symptoms significantly interfere with daily activities)*, ORIf there is no improvement in mild-moderate

Bickel, K. (2010). Carpal Tunnel Syndrome. Journal of Hand Surgery, 35 (1), pp. 147-151285-1295Massy-Westropp. N, Grimmer.K and Bain. G, (2000). A systematic review of the clinical diagnostic tests for carpal tunnel syndrome, J Hand Surgery, 25A, pp. 120–127.

Clinical threshold – refer using checklist. IFR for exceptionalityThe

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https://www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2013/11/N-SC019.pdf



https://www.nice.org.uk/guidance/TA2/documents/appendix-b-proposal-paper-presented-to-the-institutes-guidance-executive2




symptoms after 6 months conservative management which includes nocturnal splinting used for at least 8 weeks (documentation of dates and type(s) of conservative measures is required)

*This criterion includes all individuals whose symptoms are severe where six months conservative management would be detrimental to the management of the condition. Evidence should be provided to demonstrate severity of symptoms.

Gerritsen. A, de Krom. M, Struijs. M, Scholten. R, de Vet.H, Bouter. L. (2002) Conservative treatment options for carpal tunnel syndrome: a systematic review of randomised control trials. Journal Neurology, 249, pp.272-80Bland, J.(2007). Carpal Tunnel Syndrome. BMJ, 335:343-6Kruger. V, Kraft.G, Deitz.J, Ameis.A, Polissar.L. (1991). Carpal tunnel syndrome: objective measures and splint use. Arch phys Med Rehabil, 72, pp.517-20Manente. G, Torrieri. F, Di Blasio. F, Staniscia. T, Romano. F, Uncina. A. (2001). An innovative hand brace for carpal tunnel syndrome: a randomised controlled trial. Muscle Nerve, 24, pp. 1020-5.Gerritsen, A.A., Uitdehaag, B.M., van Geldere, D. et al. (2001) Systematic review of randomized clinical trials of surgical treatment for carpal tunnel syndrome. British Journal of Surgery, 88(10), pp.1285-1295Wong. S, Hui. A, Tang. A, Ho. P, Hung. L, Wong. K. (2001). Local vs systematic corticosteroids in the treatment of carpal tunnel syndrome. Neurology, 56, pp.1565-7.Marshall, S., Tardif, G. and Ashworth, N. (2007) Local corticosteroid injection for carpal tunnel syndrome (Cochrane

threshold for this procedure does not apply to Sheffield CCG – referrals should be made to the MSK service as usual

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Review). The Cochrane Library. Issue 2. John Wiley & Sons, Ltd.British Society for Surgery of the Hand. BSSH Evidence for Surgical Treatment (BEST) 1: Carpal Tunnel Syndrome.http://www.bssh.ac.uk/patients/conditions/21/carpal_tunnel_syndrome

Orthopaedics Common Hand Conditions (Dupuytren’s, Trigger Finger, Ganglion)

Dupuytren’s Disease:Referral should only be considered when the patient is having at least one of the following functional difficulties:

Moderate to severe form of the disease with notable functional impairment or/and*30 degrees or more fixed flexion at the metacarpophalangeal joint or*30 degrees or more fixed flexion at the proximal interphalangeal joint(*Inability to flatten fingers or palm on table)Ganglions:

Referral should only be undertaken when one of the following criteria are met:

Painful seed ganglia ORMucoid cysts that are disturbing nail growth or have a tendency to discharge (risk of septic arthritis in distal inter-phalangeal joint) ORIf diagnosis is in doubt

There is no indication for the routine excision of simple wrist ganglia and these should not be

British Society for Surgery of the Hand. BSSH Evidence for Surgical Treatment (BEST) 1: Dupuytren's Disease.http://www.bssh.ac.uk/patients/conditions/25/dupuytrens_disease

Davis, T. et al. Surgery for dypuytren’s contractures of the fingers. Cochrane Musculoskeletal Group. Published online 17 Oct.2012. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD010143/epdf

NICE Clinical Knowledge Summaries. Dupuytren’s disease.http://cks.nice.org.uk/dupuytrens-disease



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http://cks.nice.org.uk/dupuytrens-disease%20

http://cks.nice.org.uk/dupuytrens-disease%20

http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD010143/epdf

http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD010143/epdf

http://www.bssh.ac.uk/patients/conditions/25/dupuytrens_disease

http://www.bssh.ac.uk/patients/conditions/25/dupuytrens_disease

http://www.bssh.ac.uk/patients/conditions/21/carpal_tunnel_syndrome

http://www.bssh.ac.uk/patients/conditions/21/carpal_tunnel_syndrome


routinely referred except where there is ND deficit or severe pain.

Trigger Finger:Referral should only be undertaken when the following criteria have been met including patient record documentation of conservative treatment interventions:

Triggering with difficulty actively extending finger/need for passive finger extension orLoss of complete active flexion orFailure to respond to conservative treatment (up to 2 corticosteroid injections)

Ophthalmology Cataract Surgery

All requests for the surgical removal of cataract(s) will only be supported by the CCG when the following applies:

All requests for the surgical removal of cataract will only be supported by the CCG when the total assessment score is 7 or above as per the cataract assessment and referral form

Second eye surgery will be considered on the same basis as first eye surgery.

ExceptionsExceptions are applicable to first or second eye.

The only exceptions to the above referral criteria are as follows:

Department of Health. National Eye Care Plan (2004)The Royal College of Ophthalmologists: Cataract Surgery guidelines (2004)

NHS Executive. Action on Cataracts; Good Practice Guidance (2000).

Evans JR, Fletcher AE, Wormald RP, Ng ES. Stirling S. Prevalence of visual impairment in people aged 75 years and older in Britain: Results from the MRC trial of assessment and management of older people in the community. Br J Ophthalmol 2002; 86: 795-800

NICE Guidance Cataracts in adults:


The threshold for this procedure does not apply to Sheffield CCG

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Anisometropia (a large refractive difference between the two eyes, on average about dioptres) which would result in poor binocular vision or disabling diplopia which may increase falls.

Angle closure glaucoma including creeping angle closure and phacomorphic glaucoma

Diabetic and other retinopathies including retinal vein occlusion and age related macular degeneration where the cataract is becoming dense enough to potentially hinder management.

Oculoplastics disorders where fellow eye requires closure as part of eye lid reconstruction or where further surgery on the ipsilateral eye will increase the risks of cataract surgery

Corneal disease where early cataract removal would reduce the chance of losing corneal clarity (e.g. Fuch's corneal dystrophy or after keratoplasty)Corneal or conjunctival disease where delays might increase the risk of complications (e.g.cicatrising conjunctivitis)Other glaucoma’s (including open-angle glaucoma), inflammatory eye disease or medical retina disease where allowing a cataract to develop would hamper clinical decision making or investigations such as OCT, visual fields or

management (NG77)https://www.nice.org.uk/guidance/ng77

NICE February 2014. Eye conditions pathway http://pathways.nice.org.uk/pathways/eye-conditionsNICE guidance IPG 264. June 2008.https://www.nice.org.uk/guidance/ipg264

NICE guidance IPG 209.February 2007. http://guidance.nice.org.uk/IPG209

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fundus fluorescein angiography

Neuro-ophthalmological conditions where cataract hampers monitoring of disease (e.g. visual field changes)

Post Vitrectomy cataracts which hinder the retinal view or result in a rapidly progressing myopia.

Cataracts progress fairly rapidly following vitrectomy and are age dependent. Patients over the age of 50, especially those over 60 can have a rapid increase in the density of a cataract.

Phase 2Urology Male

circumcisionCircumcision will only be commissioned for the following indications as confirmed by an appropriate clinician:

Phimosis (inability to retract the foreskin due to a narrow prepucial ring)

Recurrent paraphimosis (inability to pull forward a retracted foreskin)

Balanitis Xerotica Obliterans (chronic inflammation leading to a rigid fibrous foreskin)

Balanoposthitis (recurrent bacterial

NHS Choices. Circumcision in adults:http://www.nhs.uk/conditions/Circumcision/Pages/Introduction.aspx (Accessed 16 January 2017)

Royal College of Surgeons. Commissioning guide: Foreskin conditions. 2013. Available from: http://www.rcseng.ac.uk/healthcare-bodies/docs/published-guides/foreskin-conditions

Moreno G, Corbalán J, Peñaloza B, Pantoja T. Topical corticosteroids for treating phimosis in boys. Cochrane


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http://www.nhs.uk/conditions/Circumcision/Pages/Introduction.aspx

http://www.nhs.uk/conditions/Circumcision/Pages/Introduction.aspx


infection of the prepuce)

Recurrent febrile urinary tract infections due to an anatomical abnormality as confirmed by a secondary care Consultant e.g. Urologist, Paediatrician

Database of Systematic Reviews 2014, Issue 9. Art. No.: CD008973. DOI: 10.1002/14651858.CD008973.pub2

Liu, Yang, Chen et al. Is steroids therapy effective in treating phimosis? A meta-analysis. Int Urol Nephrol. 2016 Mar; 48(3):335-42. doi: 10.1007/s11255-015-1184-9

Zhu, Jia, Dai et al. Relationship between circumcision and human papillomavirus infection: a systemic review and meta-analysis. Asian J Androl. 2016 March. http://www.ajandrology.com/article.asp?issn=1008-682X;year=2017;volume=19;issue=1;spage=125;epage=131;aulast=Zhu

Singh-Grewal D,Macdessi J, Craig J. Circumcision for the prevention of urinary tract infection in boys: a systematic review of randomised trials and observational studies. Arch Dis Child. 2005 Aug;90(8):853-8

Bailey RC, Moses S, Parker CB, Agot K, Maclean I, Krieger JN, et al. Male

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http://www.ajandrology.com/article.asp?issn=1008-682X;year=2017;volume=19;issue=1;spage=125;epage=131;aulast=Zhu




circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial. The Lancet. 2007;369 (9562): 643–56

General Surgery

Benign Perianal Skin Tags

Referral should only be undertaken when the following criteria have been met:There is doubt about the benign nature of the skin lesionViral warts in immunocompromised patients where underlying malignancy may be masked.Recommended by GU Med when conservative treatment has failed

NHS England. Interim Clinical Commissioning Policy: Anal Kin Tag Removalhttps://www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2013/11/N-SC002.pdfMcKinnell and Gray, 2010, QIPP Programme Right Care: Value Improvement Identifying Procedures of Low Value, Public Health Commissioning Network.Lumps and swellings NHS Choices http://www.nhs.uk/conditions/lumps-swellings/Pages/Introduction.aspx (accessed January 2017)


Dec 2018

Haemorrhoidectomy

Haemorrhoidectomy is not routinely funded for Grades I and II.The CCG will fund Haemorrhoidectomy when the following criteria are met:Recurrent third or fourth degree combined internal/external haemorrhoids ORIrreducible and large haemorrhoids with frequently reoccurring, persistent pain or bleeding ORFailed conservative treatment (including non-operative interventions: rubber band ligation, injection sclerotherapy, infrared

SSAT Patient Care Guidelines, Surgical Management of Hemorrhoids. http://www.ssat.com/cgi-bin/hemorr.cgi (accessed 16/04/17)[Haemorrhoids CKS]. 2016 [cited 23 May 2016]. Available from: http://cks.nice.org.uk/haemorrhoidsReese, G.E., von Roon, A.C. and Tekkis, P.P. (2009) Haemorrhoids. Clinical Evidence BMJ Publishing Group. http://www.ncbi.nlm.nih.gov/pmc/article


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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2907769/pdf/2009-0415.pdf

http://www.ssat.com/cgi-bin/hemorr.cgi

http://www.nhs.uk/conditions/lumps-swellings/Pages/Introduction.aspx

http://www.nhs.uk/conditions/lumps-swellings/Pages/Introduction.aspx





coagulation/photocoagulation, bipolar diathermy and direct current electrotherapy.)

s/PMC2907769/pdf/2009-0415.pdf (accessed 16/04/17)Kaidar-Person, O., Person, B. and Wexner, S.D. (2007) Hemorrhoidal disease: a comprehensive review. Journal of the American College of Surgeons 204(1), 102-117.Cataldo, P., Ellis, C.N., Gregorcyk, S. et al. (2005) Practice parameters for the treatment of hemorrhoids (revised).Diseases of the Colon & Rectum48(2), 189-194.Northwest London collaboration of clinical commissioning group. Haemorrhoidectomy. http://www.hounslowccg.nhs.uk/media/40064/21-Haemorrhoidectomy-v33.pdf (accessed 16/04/17)Wakefield Clinical commissioning group. Clinical compact for haemorrhoids. https://www.wakefieldccg.nhs.uk/wp-content/uploads/2015/06/Clinical-Compact-for-Haemorrhoids-procedures-v0.3-final.pdf (accessed 16/04/17)Herefordshire Clinical Commissioning Group Low Priority Treatment Policy 2015 http://tinyurl.com/h7a28ov (accessed 16/04/17)Nottingham North East CCG http://www.nottinghamnortheastccg.nhs.uk/wp-content/uploads/2014/04/10.-

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http://www.nottinghamnortheastccg.nhs.uk/wp-content/uploads/2014/04/10.-Policy-for-Procedures-of-Low-Clinical-Value-PLCV-Version-D-March-2011-NNE.pdf


http://tinyurl.com/h7a28ov

https://www.wakefieldccg.nhs.uk/wp-content/uploads/2015/06/Clinical-Compact-for-Haemorrhoids-procedures-v0.3-final.pdf



http://www.hounslowccg.nhs.uk/media/40064/21-Haemorrhoidectomy-v33.pdf

http://www.hounslowccg.nhs.uk/media/40064/21-Haemorrhoidectomy-v33.pdf

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2907769/pdf/2009-0415.pdf


Policy-for-Procedures-of-Low-Clinical-Value-PLCV-Version-D-March-2011-NNE.pdf (accessed 16/04/17

Orthopaedics Ingrowing Toe Nail in secondary care

Referral to secondary care should only be undertaken when:the patient is in clinical need of surgical removal of ingrowing toe nail, has been seen by a community podiatrist and has a documented allergic reaction to local anaesthetic preventing treatment in the community and a general anaesthetic will be needed. ORPeople of all ages with infection and/or recurrent inflammation due to ingrown toenail ANDwho have high medical risk*. *Medical risk is determined by the referring clinician

Eekhof JAH, Van Wijk B, Knuistingh Neven A, van der Wouden JC. Interventions for ingrowing toenails. Cochrane Database of Systematic Reviews 2012, Issue 4. Art. No.: CD001541. DOI: 10.1002/14651858.CD001541.pub3Nice.org.uk. (2016). Clinical Assessment Service: foot and ankle pathway | QP Case Study | Local practice | NICE. [online] Available at:https://www.nice.org.uk/savingsandproductivityandlocalpracticeresource?ci=http%3a%2f%2farms.evidence.nhs.uk%2fresources%2fQIPP%2f959489%2fattachment%3fniceorg%3dtrue


For Sheffield CCG refer to community podiatry service who will determine if referral to secondary care is required.

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https://www.nice.org.uk/savingsandproductivityandlocalpracticeresource?ci=http%3A%2F%2Farms.evidence.nhs.uk%2Fresources%2FQIPP%2F959489%2Fattachment%3Fniceorg%3Dtrue






Hallux Valgus

This procedure is not funded for cosmetic reasons or for asymptomatic or mild symptomatic hallux valgus.

Surgery for hallux valgus will be funded if the following criteria are met and evidenced in clinic letters:

Significant and persistent pain when walking AND conservative measures tried for at least six months (e.g. Toe spacers, bunion pads, medication or altered footwear) do not provide symptomatic relief ORulcer development at the site of the bunion or the sole of the foot ORevidence of severe deformity (overriding toes) ORPhysical examination and X-ray show degenerative changes in the 1st metatarsophalangeal joint, increased intermetatarsal angle and/or valgus deformity >15 degrees

Patient Info – Hallux valgushttp://patient.info/doctor/hallux-valgus

NICE Clinical Knowledge Summaries – Bunionshttps://cks.nice.org.uk/bunions


Dec 2018

36

https://cks.nice.org.uk/bunions

http://patient.info/doctor/hallux-valgus


Opthalmology Meibomian Cyst (Chalazion)

Referral should only be made for the following indicationsWhere conservative treatment has been tried for 3 months and has failed ANDWhere the meibomian cyst/chalazion is on the upper eyelid and interferes with vision ORIs causing persistent inflammation and pain.

Clinical Knowledge Summaries: Management of Meibomian cyst (accessed April 2017)https://cks.nice.org.uk/meibomian-cyst-chalazion#!scenariorecommendation

Paper A, Tuttle DJ, Mahar TJ. Differential diagnosis of the swollen red eyelid. Am DFam Physician. 2007 Dec 15;76(12):1815-24 http://www.ncbi.nlm.nih.gov/pubmed/12399770McKinnell and Gray, 2010, QIPP Programme Right Care: Value Improvement Identifying Procedures of Low Value, Public Health Commissioning Network http://www.aafp.org/afp/2007/1215/p1815.pdfCottrell D. G., Bosanquet R. C., Fawcett I. M. Chalazions: the frequency of spontaneous resolution. British Medical Journal. 1983;287(6405, article 1595) doi: 10.1136/bmj.287.6405.1595. [PMC free article]


Dec 2018

Blepharoplasty

Referral should only be made for the following indication:To relieve symptoms of blepharospasm or significant dermatitis on the upper eyelid caused by redundant tissue. ORFollowing skin grafting for eyelid reconstruction

Minhas A, Ronoh J., Badrinath P., 2008. “Upper Eyelid Blepharoplasty for the Treatment of Functional Problems: A Brief to the Suffolk PCT Clinical Priorities Group”. Suffolk PCT.Hacker H.D. and Hollsten D.A, 1992.

Clinical threshold – refer using checklist. IFR for exceptionali

Dec 2018

37

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1549777/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1549777/

http://www.aafp.org/afp/2007/1215/p1815.pdf

http://www.aafp.org/afp/2007/1215/p1815.pdf

http://www.ncbi.nlm.nih.gov/pubmed/12399770

http://www.ncbi.nlm.nih.gov/pubmed/12399770

https://cks.nice.org.uk/meibomian-cyst-chalazion%23!scenariorecommendation

https://cks.nice.org.uk/meibomian-cyst-chalazion%23!scenariorecommendation


ORFollowing surgery for ptosisFor all other individuals, the following criteria apply:Documented patient complaints of interference with vision or visual field related activities such as difficulty reading or driving due to upper eye lid skin drooping, looking through the eyelids or seeing the upper eye lid skin ANDThere is redundant skin overhanging the upper eye lid margin and resting on the eyelashes when gazing straight ahead AND Evidence from visual field testing that eyelids impinge on visual fields reducing field to 120° laterally and/or 20° or less superiorly.

“Investigation of automated perimetry in the evaluation of patients for upper lid blepharoplasty”. Ophthalmic, Plastic & Reconstructive Surgery 8 (4) pp. 250-255.Purewal B.K. and Bosniak S., 2005. “Theories of upper eyelid blepharoplasty”. Ophthalmology Clinics of North America 18 (2) pp 271-278.American Academy of Ophthalmology, 1995. “Functional Indications for Upper and Lower Eyelid Blepharoplasty”. Ophthalmic Procedures Assessment American Journal of Ophthalmology 102 (4) pp. 693-695.Kosmin A.S., Wishart P.K., Birch M.K., 1997. “Apparent glaucomatous visual field defects caused by dermatochalasis”. Eye 11 pp. 682-686

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Orthopaedics ArthroscopicSubacromial decompression of the shoulder (ASAD)

Patient has had symptoms for at least 3 months from the start of treatment

The patient has been assessed by Musculoskeletal Services and undertaken a minimum of six weeks of conservative treatment, as advised by and documented in primary care, such as education, rest, cessation of painful activity, a course of physiotherapy, NSAIDs and analgesia without improvement of symptoms (Saltychev M, 2015).

Symptoms are intrusive and debilitating

NICE guidance NG59 November 2016 Clinical threshold – refer using checklist. IFR for exceptionalityThe threshold for this procedure does not apply to Sheffield

Dec 2018

38


Patients have received one steroid injection from a trained physiotherapist or GP without improvement; (Normally, only one injection should be considered as repeated injections may cause tendon damage (Dean B, 2014). A second injection is occasionally appropriate after 6 weeks, but should only be administered in patients who received good initial benefit from their first injection and who need further pain relief to facilitate their structured physiotherapy treatment).

Patient has initially responded positively to a steroid injection but symptoms have returned despite compliance with conservative management

At least 8 weeks following steroid injection

Symptoms are severe and cause significant functional impairment. Significant functional impairment is defined by the BNSSG Health Community as:

1. Symptoms preventing the patient fulfilling routine work or educational responsibilities

2. Symptoms preventing the patient carrying out routine domestic or carer activities

CCG – referrals should be made to the MSK service as usual

39


Not routinely CommissionedOrthopaedics Spinal Joint

injections for low back pain

Not routinely Commissioned NICE Guidance NG 59 does not recommend offering spinal injections for low back painhttps://www.nice.org.uk/guidance/ng59

Refer through IFR for exceptionality

Acupuncture Not Routinely Commissioned except for chronic tension type headaches and migraine

NICE Guideline NG59https://www.nice.org.uk/guidance/ng59NICE CKS – Migrainehttps://cks.nice.org.uk/migraineCG 150 Headaches in over 12s – Diagnosis and Managementhttps://www.nice.org.uk/guidance/cg150/chapter/recommendations


Vasectomy under General Anaesthetic

Not Routinely CommissionedNeedle phobia is no longer an exception for this procedure


15. Plastics and fertility procedures

Speciality Procedure Commissioning Position Evidence Base Process Date of Review

Obstetrics & Gynaecology

Reversal of Female Sterilisation

Not Routinely Commissioned National supporting evidenceNHS England Interim Commissioning Policy http s://www.england.nhs.uk/commissioning/ wp-content/uploads/sites/12/2013/11/N-


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https://www.nice.org.uk/guidance/cg150/chapter/recommendations

https://www.nice.org.uk/guidance/cg150/chapter/recommendations

https://cks.nice.org.uk/migraine

https://www.nice.org.uk/guidance/ng59

https://www.nice.org.uk/guidance/ng59


SC028.pdf

Faculty of Sexual and Reproductive HealthcareClinical Guidance- Male and Female SterilisationSummary of RecommendationsClinical Effectiveness UnitSeptember 2014http://www.fsrh.org/pdfs/MaleFemaleSterilisationSummary.pdf

Obstetrics & Gynaecology

In-vitro fertilisation (IVF)/Assisted conception

IVF is approved in accordance with Policy.Prior Approval if referred via primary care

Y&H fertility policyLink for RotherhamLink for SheffieldLink for BarnsleyLink for DoncasterLink for Bassetlaw

Referral through IFR

Urology Reversal of Male Sterilisation

Not routinely commissionedReversal of sterilisation is not routinely commissioned. Informed consent for sterilisation requires that patients have understood the irreversible nature of the procedure.The clinician may still submit an application to [email protected] (safehaven) if exceptionality can be demonstrated.

National supporting evidenceNHS England Interim Commissioning Policy http s://www.england.nhs.uk/commissioning/ wp-content/uploads/sites/12/2013/11/N-SC028.pdf

Faculty of Sexual and Reproductive HealthcareClinical Guidance- Male and Female SterilisationSummary of RecommendationsClinical Effectiveness UnitSeptember 2014http://www.fsrh.org/pdfs/MaleFemaleSterilisationSummary.pdf


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http://www.fsrh.org/pdfs/MaleFemaleSterilisationSummary.pdf






http://www.bassetlawccg.nhs.uk/policies/7878-bccg-com-001-access-to-infertility-treatment-policy

http://www.doncasterccg.nhs.uk/wp-content/uploads/2017/08/YH-Fertility-Policy-2017-v6.pdf

http://www.barnsleyccg.nhs.uk/CCG%20Downloads/strategies%20policies%20and%20plans/Fertility%20Policy%202014%20-%20Barnsley.pdf

http://www.sheffieldccg.nhs.uk/Downloads/About%20US/Documents%20Policies%20and%20Publications/YH%20Fertility%20Policy%202017%201.pdf

http://www.rotherhamccg.nhs.uk/Downloads/Policies%20and%20Procedures/Individual%20Funding%20Request%20Policies/YH%20Fertility%20Policy%20April%202017%20v7.pdf





Plastic and Cosmetic surgery

FaceliftBrowlift

Facelift procedures and Botulinum toxin will not be routinely commissioned by the NHS for cosmetic reasons

Cases may be considered on an exceptional basis, for example in the presence of an anatomical abnormality or a pathological feature which significantly affects appearance.

Policy for specialist plastic surgery procedures Link


Updated May 2016ReviewMay 2018


Abdominoplasty/apronectomy (tummy tuck)

Abdominoplasty will not be routinely commissioned by the NHS for cosmetic reasons.

Abdominoplasty may rarely be considered on an exceptional basis, for example where the patient:

has lost a significant amount of weight (moved down two levels of the BMI SIGN guidance) and has a stable BMI, which would normally be below 27 for a minimum of 2 years, and

is experiencing severe difficulties with daily living, for example ambulatory or urological restrictions.

Other factors may be considered:

recurrent severe infection or ulceration beneath the skin fold

significant abdominal wall deformity due to surgical scarring or trauma



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http://www.rotherhamccg.nhs.uk/individual-funding-request-policies.htm



Buttock, thigh and Arm lift surgery

Not Routinely Commissioned

Surgery to remove excess skin from the buttock, thighs and arms will not be routinely commissioned by the NHS for cosmetic reasons.

Cases may be considered on an exceptional basis, for example where the patient:

has an underlying skin condition, for example cutis laxa or

has lost a considerable amount of weight resulting in severe mechanical problems affecting activities of daily living and

has a normal BMI in the range18.5 - 27 for a minimum of 2 years

Policy for specialist plastic surgery procedures




Breast Augmentation

Breast augmentation will not be routinely commissioned by the NHS for cosmetic reasons, for example for small normal breasts or for breast tissue involution (including post-partum changes).

Breast augmentation may rarely be considered on an exceptional basis, for example where the patient:

has a complete absence of breast tissue either unilaterally or bilaterally or

has suffered trauma to the breast during or after development and

has a BMI within the range 18.5 - 27 or 18.5 – 25 for Doncaster and

has completed puberty as surgery is not routinely commissioned for individuals who are below 19 years of age




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Patients who have received feminising hormones for an adequate length of time as part of a recognised treatment programme for gender dysphoria will only be considered when they meet the above criteria.

Revision surgery will only be commissioned for implant failure or for other physical symptoms, for example capsule contracture associated with pain, and not for aesthetic indications.

Implant replacement will only be considered if the original procedure was performed by the NHS.

For Doncaster: If the criteria above are met then the patient will be referred to Nottingham for a breast scan, for objective information regarding this request.3 breast scans will be undertaken. These are:• BMI• Breast Volume• Breast : Torso RatioThe patient must pass BMI test and one other test to be eligible for funding


Breast Reduction


Breast reduction will not routinely be commissioned by the NHS for cosmetic reasons.

Breast reduction may rarely be considered on an exceptional basis, for example where the patient:

has a breast measurement of cup size G or larger and

has a BMI in the range 18.5 - 27 or 18.5 – 25 for Doncaster and

National supporting evidenceNHS England Interim Commissioning Policy for Breast Reduction November 2013:https://www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2013/11/N-SC005.pdf



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is 19 years of age or over and has significant musculo-skeletal pain

causing functional impairment which in the opinion of the referrer is likely to be corrected or significantly improved by surgery and

has tried and failed with all other advice and support, including a professional bra fitting and assessment by a physiotherapist where relevant

For Doncaster: If the criteria above are met then the patient will be referred to Nottingham for a breast scan, for objective information regarding this request.3 breast scans will be undertaken. These are:• BMI• Breast Volume• Breast : Torso RatioThe patient must pass all 3 tests to be eligible for funding


Breast Reduction for male gynaecomastia


Surgery to correct gynaecomastia will not routinely be commissioned by the NHS for cosmetic reasons.

Surgery may be considered on an exceptional basis, for example where the patient:

has more than 100g of sub areolar gland and ductal tissue (not fat) and

has a BMI in the range 18.5 - 27 or 18.5 – 25 for Doncaster and

has been screened prior to referral to exclude endocrinological and drug related causes

o if drugs have been a factor then a period of one year since last use

National supporting evidenceNHS England Interim Commissioning Policy for Breast Reduction for Gynaecomastia (male) November 2013:https://www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2013/11/N-SC006.pdf



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should have elapsed and

has completed puberty - surgery is not routinely commissioned below the age of 19 years and

has been monitored for at least 1 year to allow for natural resolution if aged 25 or younger


Breast Asymmetry


Surgery to correct breast asymmetry will not routinely be commissioned by the NHS for cosmetic reasons.

Surgery may rarely be considered on an exceptional basis, for example where the patient:

has a difference of at least 2 cup sizes and has a BMI in the range 18.5-27 or 18.5 – 25

for Doncaster and has tried and failed with all other advice

and treatment, including a professional bra fitting and

has completed puberty - surgery is not normally commissioned below the age of 19 years

For Doncaster: If the criteria above are met then the patient will be referred to Nottingham for a breast scan, for objective information regarding this request.5 breast scans will be undertaken. These are:• BMI• Volume• Nipple to Fold• Areola Diameter• Notch to Nipple

National supporting evidenceNHS England Interim Commissioning Policy for Breast Asymmetry November 2013:https://www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2013/11/N-SC003.pdf



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The patient must pass BMI test and one other test to be eligible for funding


Breast lift mastopexy


Mastopexy will not be routinely commissioned by the NHS for cosmetic reasons, for example post lactation or age related ptosis but may be included as part of the treatment to correct breast asymmetry.





Correction of Nipple inversion


Surgical correction of benign nipple inversion will not be routinely commissioned by the NHS for cosmetic reasons.





Hair removal Not Routinely Commissioned

Hair removal will not be routinely commissioned by the NHS for cosmetic reasons.

Hair removal may be considered on an exceptional basis, for example where the patient:

has had reconstructive surgery resulting in abnormally located hair bearing skin or

has a pilonidal sinus resistant to conventional treatment in order to reduce recurrence risk





Hair transplantation


Hair transplantation will not be routinely commissioned by the NHS for cosmetic reasons, regardless of gender.




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Hair transplantation may be considered on an exceptional basis, for example when reconstruction of the eyebrow is needed following cancer or trauma.


Acne scarring Procedures to treat facial acne scarring will not be routinely commissioned by the NHS.

Cases may be considered on an exceptional basis, for example when the patient has very severe facial scarring unresponsive to conventional medical treatments.





Pinnaplasty Not Routinely Commissioned

Surgical correction of prominent ears will not be routinely commissioned by the NHS for cosmetic reasons.Cases may be considered on an exceptional basis, for example where the patient:

is aged 5-19 at the time of referral and the child (not the parents alone) expresses concern and

has very significant ear deformity or asymmetry





Rhinoplasty Not Routinely Commissioned

Rhinoplasty will not be routinely commissioned by the NHS for cosmetic reasons.

Cases may be considered on an exceptional basis, for example in the presence of severe functional




48


problems.

Post traumatic airway obstruction or septal deviation does not need funding approval.


Rhinophyma Not Routinely Commissioned

Surgical/laser treatment of rhinophyma will not be routinely commissioned by the NHS for cosmetic reasons.

Cases may be considered on an individual basis, for example where the patient has functional problems and where conventional medical treatments have been ineffective.





Revision of Surgical Scars


Revision surgery for scars will not be routinely commissioned by the NHS for cosmetic reasons.


has significant deformity, severe functional problems, or needs surgery to restore normal function or

has a scar resulting in significant facial disfigurement.





Congenital vascular abnormalities


Procedures for congenital vascular abnormalities will not be routinely commissioned by the NHS for cosmetic reasons.

Cases may be considered on an exceptional basis




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for lesions of considerable size on exposed areas only.


Thread vein/telangectasia

Not Routinely Commissioned Policy for specialist plastic surgery procedures




Tattoo removal

Tattoo removal will not be routinely commissioned by the NHS.


has suffered a significant allergic reaction to the dye and medical treatments have failed

has been given a tattoo against their will (rape tattoo)

National supporting evidenceNHS England Interim Commissioning Policy for Tattoo Removal November 2013https://www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2013/11/N-SC032.pdf




Reduction of labia minora (Labioplasty)

Not Routinely Commissioned Policy for specialist plastic surgery procedures




Liposuction Not Routinely Commissioned

Liposuction will not be routinely commissioned by the NHS for cosmetic reasons.

Cases may be considered on an exceptional basis, for example where the patient has significant lipodystrophy.




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16. Clinical Threshold Checklists

Grommets for Otitis Media with Effusion in Children

Instructions for use:To Referring Clinicians (e.g. GP’s): Please refer to the above policy and complete the following form prior to referral.To Receiving Clinician: Please refer to the full policy, and ensure there is evidence that the criteria selected are met. Please file for future compliance audit.

The CC G w i l l o n l y f u n d Gr o mm e ts f o r Ot i t i s M e d i a wi th E ffus i on i n ch i l dren ( a g e u n d e r 18 y e a rs) w h e n t he fo ll o wi ng cr i teria a re met :

In ordinary circumstances*, referral should not be considered unless the patient meets one or more of the following criteria when presenting in a Primary Care setting:

Delete asappropriate

Recurrent acute otitis media - 5 or more recorded episodes in the preceding 12 month period. Yes No

Suspected hearing loss at home or at school / nursery following 3 months of watchful waiting Yes No

Speech delay, poor educational progress due to the hearing loss Yes No

Abnormal appearance of tympanic membrane Yes No

In ordinary circumstances*, a procedure should not be considered unless the patient meets one or more of the following criteria when presenting in a Secondary Care setting:

Delete as appropriate

Persistent hearing loss for at least three months (in any setting) with hearing levels of: 25dBA or worse in both ears on pure tone audiometry or 25dBA or worse or 35dHL or worse on free field audiometry testing and Type B or C2 tympanometry

Yes No

Suspected underlying sensorineural hearing loss Yes No

Atelectasis of the tympanic membrane where development of cholesteatoma or erosion of the ossicles is a risk.

Yes No

OME in the presence of a secondary disability e.g. autistic spectrum disorder, Down syndrome, cleft palate.

Yes No

Persistent OME (more than three months) with fluctuating hearing but significant delay in speech, educational attainment or social skills.

Yes No

* If clinician considers need for referral/treatment on clinical grounds outside of these criteria, please refer to the CCG’s Individual funding request policy for further information.

As the presence of a second disability such as Down’s syndrome or cleft palate can predispose children to OME in such children it is left to the clinician’s discretion how far this policy will apply.

Please send this form with the referral letter.

Patient Name:Address:Date of Birth:NHS NumberConsultant/Service to whom referral will be made:

51

Grommets in Adults

Instructions for use:To Referring Clinicians (e.g. GP’s): Please refer to the above policy and complete the following form priorto referral.To Receiving Clinician: Please refer to the full policy, and ensure there is evidence that the criteria selected are met. Please file for future compliance audit.

The CCG will only fund Grommets for Adults (Aged 18 and over) when the following criteria are met:

In ordinary circumstances*, referral should not be considered unless the patient meets one or more of the following criteria.


Persistent hearing loss for at least 3 months with hearing levels of 25dB r worse on pure tone audiometry or

Yes No

Recurrent acute otitis media – 5 or more episodes in the preceding 12 month period or Yes NoEustachian tube dysfunction causing pain or Yes NoAtelectasis of the tympanic membrane where development of cholesteatoma or erosion of the ossicles is a risk or

Yes No

As a conduit for drug delivery direct to the middle ear or Yes NoIn the case of conditions e.g. nasopharyngeal carcinoma, ethmoidal cancer, maxillectomy, olfactory neuroblastoma, sinonasal cancer, and complications relating to its treatment (including radiotherapy), if judged that the risks outweigh the benefit by the responsible clinician or

Yes No

Part of a more extensive procedure at Consultant’s discretion such as tympanoplasty, acute otitis media with facial palsy

Yes No

* If clinician considers need for referral/treatment on clinical grounds outside of these criteria, please refer to the Individual funding request policy for further information.



52

Tonsillectomy


The CCG w i l l o nl y f u n d T o n s i ll ecto m y w h en t he f ol l o w i ng c r i ter i a h a v e b e e n m e t :

A s ix m o nth p e r iod of w atchful w aiting is r e c om m e nded p r i or to r efe r r al f o r tonsi l le c to m y to e s tabl i sh a pat t e r n of s y m p toms and to a l low the patient time to fully consid e r t h e i m p l i c a tio n s of the op e r ation

In ordinary circumstances*, referral should not be considered unless the patient meets one or more of the following criteria when presenting in a Primary Care setting:


Recurrent attacks of tonsillitis 7 or more well documented, clinically significant**, adequately treated sore throats in

the preceding year OR 5 or more such episodes in each of the preceding 2 years OR 3 or more such episodes in each of the preceding 3 years

Yes No

Two or more episodes of quinsy (peri-tonsillar abscess) Yes No

Severe halitosis secondary to tonsillar crypt debris Yes No

Failure to thrive secondary to difficulty swallowing caused by very enlarged tonsils. Yes No

In ordinary circumstances*, referral should not be considered unless the patient meets one or more of the following criteria when presenting in a Secondary Care setting:


Sleep disordered breathing or obstructive sleep apnoea diagnosed on overnight pulse oximetry or polysomnography.

Yes No

Biopsy / removal of lesion on tonsil Yes No

* If clinician considers need for referral/treatment on clinical grounds outside of these criteria, please refer to the CCG Individual funding request policy for further information.

** A Clinically significant episode is characterised by at least one of the following:o Oral temperature of at least 38.30C requiring antibiotic treatmento Tender anterior cervical lymph nodes.o Tonsillar exudates.



53

Varicose VeinsInstructions for use: Please refer to the full policy for details.

To Referring Clinicians and Receiving Clinicians: Treatment of varicose veins in secondary care is considered a low priority treatment and will only be funded by the CCG if the criteria below have been met. Treatment will NOT be funded for cosmetic reasons or in pregnancy.

Patients may be referred to secondary care for treatment of their varicose veins if they meet the commissioning criteria:

Please tick one

Patient’s BMI is 30 or less ANDIntractable ulceration secondary to venous stasis ORBleeding varicose vein or if the patient is at high risk of re-bleeding. (i.e. there has been more than one episode of minor haemorrhage or one episode of significant haemorrhage from a ruptured superficial varicosity.) ORSignificant and or progressive lower limb skin changes such as Varicose eczema, or lipodermatosclerosis with moderate to severe oedema proven to be caused by chronic venous insufficiency (itching is insufficient for referral). ORRecurrent thrombophlebitis (more than 2 episodes) associated with severe and persistent pain requiring analgesia and affecting activities of daily living and or instrumental activities of daily living*. ORIf the patient is severely symptomatic affecting activities of daily living and or instrumentalactivities of daily living. - ALL below must apply:

Symptoms must be caused by varicosity and cannot be attributed to any other comorbidities or other disease affecting the lower limb.

There must be a documented unsuccessful six month trial of conservative management.**

Evidence that symptoms are affecting activities of daily living and/or Instrumental activities of daily living.

*Activities of daily living include: functional mobility, eating, bathing and personal care. They can be measured using the Barthel activities of daily living index. Instrumental activities of daily living include more complex tasks such as care of others, community mobility, health management and meal preparation.** Conservative management should include advice on walking and exercise, avoidance of activities that exacerbate symptoms, leg elevation whenever sitting and weight loss if appropriate. Compression stockings should only be used where interventional treatment is unsuitable or the patient fails to meet the criteria.

If clinician considers need for referral/treatment on clinical grounds outside of these criteria, please refer to CCG’s Individual funding request policy for further information.



54

Management of Benign Skin Lesions


The CCG will only fund management of benign skin lesions when one or more of the following criteria are met:

Where it is safe to do so, every attempt should be made to manage benign skin lesions inprimary care/community setting provided removal would not be purely cosmetic.


Diagnostic uncertainty exists and there is suspicion of malignancy (please refer as appropriate and following telederm where available)

Yes No

The lesion is painful or impairs function and warrants removal, but it would be unsafe to do so in primary care/community setting, for example because of large size (>10mm), location (e.g. face or breast) or bleeding risk. Removal would not be purely cosmetic.

Yes No

Viral warts in immunosuppressed patients. Yes NoPatient scores >20 in Dermatology Life Quality Index* administered during a consultationwith the GP or other healthcare professional.

Yes No

*See http://www.dermatology.org.uk/quality/dlqi/quality-dlqi.html for information on the use of the Dermatology Life Quality Index.

This policy does not apply to treatment of benign skin lesions in perianal area.

If clinician considers need for referral/treatment on clinical grounds outside of these criteria, please refer to the Individual Funding Request policy for further information.



Patient Name:Address:Date of Birth:NHS Number

55


Hysterectomy and Hysteroscopy for Management of Heavy Menstrual Bleeding

Instructions for use:To Secondary Care Clinician: Please refer to the full policy, and ensure there is evidence that the criteria selected are met. Please file for future compliance audit.

The CCG will only fund Hysterectomy or Hysteroscopy when the following criteria are met:Patients WILL NOT receive a D&C:

As a diagnostic tool ALONE for heavy menstrual bleeding, or As a therapeutic treatment for heavy menstrual bleeding.

Patients WILL receive hysterectomy or hysteroscopy in the investigation and management of heavymenstrual bleeding only when the following criteria are met respectively for each procedure:

*Hysteroscopy for HMB will only be funded if ONE of the following criteria is met:Trans vaginal ultrasound scan provided inconclusive results Yes NoTrans vaginal ultrasound scan was suggestive of endometrial pathology (e.g. polyp or submucous fibroid).

Yes No

As part of an ablative procedure Yes NoInter-menstrual bleeding over the age of 40yrs Yes NoScan suggests thickened and cystic appearance/hyperplasia Yes No*The hysteroscopy element of this Checklist does not apply to Doncaster CCG. Normal referral process applies.Hysterectomy for HMB will only be funded if ALL the following criteria are met:A levonorgestrel intrauterine system or LNG-IUS (e.g. Mirena) has been trialled for at least 6 months (unless contraindicated) and has not successfully relieved symptoms.

Yes No

A trial of at least 3 months each of two other pharmaceutical treatment options has not effectively relieved symptoms (or is contraindicated, or not tolerated). These treatment options include:

NSAIDs e.g. mefenamic acid Tranexamic acid Combined oral contraceptive pill Oral and injected progestogens

Yes No

Surgical treatments such as endometrial ablation, thermal balloon ablation, microwave endometrial ablation or uterine artery embolisation (UAE) have either been ineffective or are not appropriate, or are contraindicated

Yes No

If clinician considers need for referral/treatment on clinical grounds outside of these criteria, please refer to the Individual funding request policy for further information.

Patient Name:Address:Date of Birth:NHS Number

56

Management of Gall bladder disease including **mild and asymptomatic/incidental gallstones

Instructions for use:To Referring Clinicians (e.g. GP’s): Please refer to the above policy and complete the form prior to referral.

To Receiving Clinician: Please refer to the full policy, and ensure there is evidence that the criteria selected are met. Please file for future compliance audit.

The CCG will only provide funding for cholecystectomy in **mild (see policy) or asymptomatic gallstones if one or more of the following criteria are met:


*High risk of gall bladder cancer, e.g. gall bladder polyps ≥1cm, porcelain gall bladder, strong family history (parent, child or sibling with gallbladder cancer).

Yes No

Transplant recipient (pre or post-transplant). Yes NoDiagnosis of chronic haemolytic syndrome by a secondary care specialist. Yes NoIncreased risk of complications from gallstones, e.g. presence of stones in thecommon bile duct, stones smaller than 3mm with a patent cystic duct, presence of multiple stones.

Yes No

Acalculus cholecystitis diagnosed by a secondary care specialist. Yes No* (Annual USS for smaller asymptomatic polyps)

The CCG will continue to fund cholecystectomy for patients with moderate to severely symptomatic gallstones:Patient has moderate or severely symptomatic gallstones and agrees to surgery Yes No

** The threshold in respect of mild (one episode of mild abdominal pain) does not apply to Doncaster, Bassetlaw and Sheffield CCG

If clinician considers need for referral/treatment on clinical grounds outside of these criteria, please refer to the Individual Funding Request policy for further information.



57

Surgical Repair of Hernias

Instructions for use:To Referring Clinicians (e.g. GP’s): Please refer to the above policy and complete the following form prior to referral.To Receiving Clinician: Please refer to the full policy, and ensure there is evidence that the criteria selected are met. Please file for future compliance audit. (This policy only applies to patients aged over 16 years)PATIENTS WITH DIVERIFICATION OF THE RECTI SHOULD NOT BE REFERRED FOR SURGICAL OPINIONThe CCG will only fund inguinal hernia surgery when the following criteria are met :In ordinary circumstances*, referral/treatment should not be considered unless the patient meets one or more of the following criteria.


Symptomatic hernias i.e. those which limit work or activities of daily living OR Yes NoHernias that are difficult or impossible to reduce Yes NoInguino-scrotal hernias Yes NoAn increase in the size of the hernia month on month (please use your clinical discretion when referring/surgical repair of these patients)

Yes No

*If clinician considers need for referral/treatment on clinical grounds outside of these criteria, please refer to the Individual funding request policy for further information.

Please note that for asymptomatic or minimally symptomatic inguinal hernias, the CCG advocates a watchful waiting approach (informed consent regarding the potential risks of developing hernia complications e.g. incarceration, strangulation, or bowel obstruction). Patients should also be advised regarding weight loss as appropriate.

The CCG will only fund umbilical, para umbilical and midline ventral hernia surgery when the following criteria are met:In ordinary circumstances*, referral/treatment should not be considered unless the patient meets one or more of the following criteria.


Pain or discomfort interfering with ADL OR Yes NoAn increase in the size of the hernia month on month OR Yes NoTo avoid strangulation and incarceration of bowel where hernia is > 2cm Yes No

The CCG will only fund Incisional hernia surgery when the following criteria are met: In ordinary circumstances*, referral should not be considered unless the patient meets the following criteria.


Pain or discomfort interfering with Activities of Daily Living Yes No

The CCG will only fund femoral hernia surgery when the following criteria are met:

All suspected femoral hernias must be referred to secondary care due to the increased risk of incarceration/ strangulation

Yes No



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Hip Replacement

Instructions for use:To Referring Clinicians (e.g. GP’s): Please refer to the above policy and complete the following form prior to referral.

To Receiving Clinician: Please refer to the full policy, and ensure there is evidence that the criteria selected are met. Please file for future compliance audit.The CCG will only fund hip replacement for osteoarthritis if the following criteria have been met:


Referral to the Hip Pathway AND Yes NoPatient has a BMI of less than 35 (Patients with BMI>35 should be referred for weight management interventions and upon 6 months of documented weight loss attempt with dates and intervention types- if the patient fails to lose weight to a BMI less than 35 then may consider referral through the IFR process.) AND EITHER

Yes No

Intense to severe persistent pain (defined in table one and documentation to support is required) which leads to severe functional limitations (defined in table two and documentation to support is required), OR

Yes No

Moderate to severe functional limitation (defined in table two and documentation to support is required) affecting the patients quality of life despite 6 months of conservative measures*

Yes No

If clinician considers need for referral/treatment on clinical grounds outside of these criteria, please refer to The CCG’s Individual funding request policy for further information.

*Conservative measures = oral NSAIDs, physiotherapy or referral to the Hip Referral Pathway, and paracetamol based analgesics and patient education (e.g. activity / lifestyle modification). Documentation of dates and types of conservative measures required to be included with this form.

Table 1: Classification of pain levelPain level

Slight

Sporadic pain.(May be daily but comes and goes 25% or less of the day)Pain when climbing/descending stairs.Allows daily activities to be carried out (those requiring great physical activity may be limited). (Able to bathe, dress, cook, and maintain house)Medication, aspirin, paracetamol or NSAIDs to control pain with no/few side effects

Moderate

Occasional pain.(May be daily and occurs 50-75% of the day)Pain when walking on level surfaces (half an hour, or standing).Some limitation of daily activities.(Occasionally has difficulty with self-care and home maintenance)Medication, aspirin, paracetamol or NSAIDs to control with no/few side effects.

Intense/Severe

Pain of almost continuous nature.(Occurs 75-100% of the day)Pain when walking short distances on level surfaces (>20ft) or standing for less than half an hour or pain when restingDaily activities significantly limited. (unable to maintain home, cook, bathe or dress without difficulty or assistance)



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Continuous use of NSAIDs or narcotics for treatment to take effect or no responseRequires the use of support systems (walking stick, crutches).

Table 2: Functional Limitations

MinorFunctional capacity adequate to conduct normal activities and self-careWalking capacity of more than one hourNo aids needed

Moderate

Functional capacity adequate to perform only a few of the normal activities and self-careWalking capacity of between half and one hourAids such as a cane are needed occasionally

SevereLargely or wholly incapacitatedWalking capacity of less than half hourCannot move around without aids such as a cane, a walker or a wheelchair. Help of a carer is required.

If the above criteria are not met, does the patient meet the following exceptions:–Patients whose pain is so severe and/or mobility is compromised that they are in immediate danger of losing their independence and that joint replacement would relieve this. (Refer through IFR)

Yes No

Patients whom the destruction of their joint is of such severity that delaying surgicalcorrection would increase the technical difficulties of the procedure.(Refer through IFR)

Yes No

Rapid onset of severe hip pain Yes No

Patients with co-morbidities should be optimised prior to referral for possible surgeryDiabetes Hypertension Anaemia Sleep Apnoea

HbA1c < 70 nmol/ml BP < 160/100Aim for 140/85 non

DiabeticAim for 140/80 Diabetic

Hb > 13 in menHb > 12 in women

Referred for Sleep Studies with STOP

BANG Score> 5

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Knee replacement

Instructions for use:To Referring Clinicians (e.g. GP’s): Please refer to the above policy and complete the following form prior to referral.

To Receiving Clinician: Please refer to the full policy, and ensure there is evidence that the criteria selected are met. Please file for future compliance audit.The CCG will only fund knee replacement for osteoarthritis when the following criteria have been met Delete as

appropriateReferral has been made to the Knee Pathway AND Yes NoPatient has a BMI of less than 35 (Patients with BMI>35 should be referred to for weight management interventions) and upon 6 months of documented weight loss attempt with dates and intervention types- if the patient fails to lose weight to a BMI less than 35 then may consider referral through the IFR process.) AND

Yes No

Osteoarthritis of the knee causes persistent, severe pain as defined in table 1 AND Yes NoPain from osteoarthritis of the knee leads to severe loss of functional ability and reduction in quality of life as defined in table 2 AND

Yes No

Symptoms have not adequately responded to 6 months of conservative measures* OR conservative measures are contraindicated. Documentation of dates and types of measures is required.

Yes No

If clinician considers need for referral/treatment on clinical grounds outside of these criteria, please refer to the Individual funding request policy for further details.*Conservative measures =, oral NSAIDs, physiotherapy or referral to the Knee Referral Pathway and paracetamol based analgesics, intra-articular corticosteroid injections and patient education (e.g. activity / lifestyle modification). See policy for further details.

Table 1: Classification of pain levelPain level

Slight

Sporadic pain.(May be daily but comes and goes 25% or less of the day)Pain when climbing/descending stairs.Allows daily activities to be carried out (those requiring great physical activity may be limited). (Able to bathe, dress, cook, and maintain house)Medication, aspirin, paracetamol or NSAIDs to control pain with no/few side effects

Moderate

Occasional pain.(May be daily and occurs 50-75% of the day)Pain when walking on level surfaces (half an hour, or standing).Some limitation of daily activities.(Occasionally has difficulty with self-care and home maintenance)Medication, aspirin, paracetamol or NSAIDs to control with no/few side effects.

Intense/Severe

Pain of almost continuous nature.(Occurs 75-100% of the day)Pain when walking short distances on level surfaces (>20ft) or standing for less than half an hour or pain when restingDaily activities significantly limited. (unable to maintain home, cook, bathe or dress without difficulty or assistance)Continuous use of NSAIDs or narcotics for treatment to take effect or no response



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Requires the use of support systems (walking stick, crutches).

Table 2: Functional Limitations

MinorFunctional capacity adequate to conduct normal activities and self-careWalking capacity of more than one hourNo aids needed

Moderate

Functional capacity adequate to perform only a few of the normal activities and self-careWalking capacity of between half and one hourAids such as a cane are needed occasionally

SevereLargely or wholly incapacitatedWalking capacity of less than half hourCannot move around without aids such as a cane, a walker or a wheelchair. Help of a carer is required.

If the above criteria are not met, does the patient meet the following exceptions:–Patients whose pain is so severe and/or mobility is compromised that they are in immediate danger of losing their independence and that joint replacement would relieve this. (Refer through IFR)

Yes No

Patients whom the destruction of their joint is of such severity that delaying surgicalcorrection would increase the technical difficulties of the procedure. (Refer through IFR)

Yes No

Patients with co-morbidities should be optimised prior to referral for possible surgeryDiabetes Hypertension Anaemia Sleep Apnoea

HbA1c < 70 nmol/ml BP < 160/100Aim for 140/85 non

DiabeticAim for 140/80 Diabetic

Hb > 13 in menHb > 12 in women

Referred for Sleep Studies with STOP

BANG Score> 5

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Carpal Tunnel Syndrome Surgery.

Instructions for use:To Referring Clinicians (e.g. GP’s): Please refer to the above policy and complete the following form priorto referral.To Receiving Clinician: Please refer to the full policy, and ensure there is evidence that the criteria selected are met. Please file for future compliance audit.

The CCG will only fund Carpal Tunnel Surgery when the following criteria are met:



**Severe symptoms at presentation (including sensory blunting, muscle wasting, weakness on thenar abduction or symptoms that significantly interfere with daily activities)***

Yes No

If there is no improvement in mild-moderate symptoms after 6 months conservative management which includes nocturnal splinting used for at least 8 weeks (documentation of dates and type(s) of conservative measures is required)

Yes No

* If clinician considers need for referral/treatment on clinical grounds outside of these criteria, please refer to the individual funding requests policy for further information.

**This criterion includes all individuals whose symptoms are severe where six months conservative management would be detrimental to the management of the condition. Evidence should be provided to demonstrate severity of symptoms.

*** plus CTS score of 5 or more for Doncaster, Bassetlaw and Sheffield



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Common Hand Conditions – Dupuytren’s Disease

Instructions for use:To Referring Clinicians (e.g. GP’s): Please refer to the above policy and complete the following form priorto referral.


The CCG will only fund correction of Dupuytren’s disease when the following criteria are met :

In ordinary circumstances*, referral should not be considered unless the patient meets the following criteria.


Moderate to severe form of the disease with notable functional impairment or/and Yes No**30 degrees or more fixed flexion at the metacarpophalangeal (MCPJ)joint or Yes No**30 degrees or more fixed flexion at the proximal interphalangeal (PIPJ) joint Yes No


** Inability to flatten fingers or palm on table



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Common Hand Conditions – Trigger Finger



The CCG will only fund Trigger finger correction when the following criteria are met:In ordinary circumstances*, referral should not be considered unless the patient meets one of the following criteria.


Triggering with difficulty actively extending finger/need for passive finger extension or Yes NoLoss of complete active flexion or Yes NoFailure to respond to conservative treatment (up to 2 corticosteroid injections)** Yes No** Where injection of trigger finger is not available in primary care, please refer to MSK CATS for this treatment




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Common Hand Conditions – Ganglions


There is no indication for the routine excision of simple wrist ganglia and these should not be routinely referred except where there is ND deficit or severe pain. (Refer through IFR)

To Receiving Clinician: Please refer to the full policy, and ensure there is evidence that the criteria selected are met. Please file for future compliance audit.The CCG will only fund correction of Ganglion(s) when the following criteria are met: In ordinary circumstances*, referral should not be considered unless the patient meets one of the following criteria.


Painful seed ganglia Yes NoMucoid cysts that are disturbing nail growth or have a tendency to discharge (risk of septic arthritis in distal inter-phalangeal joint)

Yes No

If the diagnosis is in doubt Yes No

*If clinician considers need for referral/treatment on clinical grounds outside of these criteria, please refer to The Individual funding request policy for further information



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Please send this form with the referral letter

Cataract Surgery

Instructions for use:

To Consultants:First Eye Surgery: Where a patient has been referred outside of the Cataract LES, the Consultant must ensure that the patient meets the Clinical Threshold. Please complete Part 1 and 2.Second Eye Surgery: Please complete Part 1 and 3.

The CCG will only fund Cataract Surgery, when the following criteria are met:

Part 1 - Assessment

VA ScoresVA 6/6 = 0VA 6/9 = 1VA 6/12 = 2VA 6/18 = 7

SPH CYL AXS VA Dominant Eye

Score

R VA Score

L

Lifestyle Questions to ask patient* Not at all Slightly Moderately Very MuchIs the patient’s quality of life affected by vision difficulties (e.g. car driving, watching TV, doing hobbies, etc?)Is the patient’s social functioning affected by vision difficulties (e.g. crossing roads, recognising people, recognising coins etc?)*These questions are designed to elicit the information from pts as to the effect on their lifestyle. The clinician will use the responses to weight the scoring below

Circle Score Yes NoAny difficulties for patient with mobility (including aspect of travel, e.g. driving, using public transport)?

2 0

Is the patient affected by glare in sunlight or night (car headlights)? 2 0Is the patient’s vision affecting their ability to carry out daily tasks? 2 0

Part 2 - First Eye Cataract Surgery

FIRST EYE TOTAL ASSESSMENT SCORE (VA AND LIFESTYLE SCORE)

NB: THE PATIENT MUST HAVE A TOTAL ASSESSMENT SCORE OF 7 TO MEET THE THRESHOLD FOR FIRST EYE SURGERY OR THE PATIENT MEETS ONE THE EXCEPTIONS (PLEASE DOCUMENT IN PART 4)

The patient meets the Clinical Threshold for first eye cataract surgery Yes No

Patient Name:Address:Date of Birth:NHS Number:Consultant/ Service to whom referral will be made:

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Part 3 - Second Eye Cataract Surgery

Complete Part 1 for Second Eye

SECOND EYE TOTAL ASSESSMENT SCORE (VA AND LIFESTYLE SCORE)

NB: THE PATIENT MUST HAVE A TOTAL ASSESSMENT SCORE OF 7 TO MEET THE THRESHOLD FOR SECOND EYE SURGERY OR THE PATIENT MEETS ONE THE EXCEPTIONS (PLEASE DOCUMENT IN PART 4)

The patient meets the Clinical Threshold for second eye cataract surgery. Yes No

Part 4 - Exceptions Exceptions are applicable to first or second eye.

The only exceptions to the referral criteria are as follows: Delete as appropriate

Anisometropia (a large refractive difference between the two eyes, on average about 3 dioptres), which would result in poor binocular vision or disabling diplopia which may increase the risk of falls.

Yes No

Angle closure glaucoma including creeping angle closure and phacomorphic glaucoma Yes NoDiabetic and other retinopathies including retinal vein occlusion and age related maculardegeneration where the cataract is becoming dense enough to potentially hinder management.

Yes No

Oculoplastics disorders where fellow eye requires closure as part of eye lid reconstruction orwhere further surgery on the ipsilateral eye will increase the risks of cataract surgery

Yes No

Corneal disease where early cataract removal would reduce the chance of losing corneal clarity (e.g. Fuch's corneal dystrophy or after keratoplasty)

Yes No

Corneal or conjunctival disease where delays might increase the risk of complications (e.g.cicatrising conjunctivitis)

Yes No

Other glaucoma’s (including open-angle glaucoma), inflammatory eye disease or medical retina disease where allowing a cataract to develop would hamper clinical decision making orinvestigations such as OCT, visual fields or fundus fluorescein angiography

Yes No

Neuro-ophthalmological conditions where cataract hampers monitoring of disease (e.g. visual field changes)

Yes No

Post vitrectomy cataracts which hinder the retinal view or result in a rapidly progressing myopia.

Yes No

If clinician considers need for referral/treatment on clinical grounds outside of these criteria, please refer to the CCG’s Individual funding request policy for further information

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Male Circumcision



The CCG will only fund male circumcision when the following criteria are met:



Phimosis (inability to retract the foreskin due to a narrow prepucial ring) or recurrent paraphimosis (inability to pull forward a retracted foreskin)

Yes No

Balanitis Xerotica Obliterans (chronic inflammation leading to a rigid fibrous foreskin) Yes NoBalanoposthitis (recurrent bacterial infection of the prepuce). Yes NoRecurrent febrile urinary tract infections due to an anatomical abnormality as confirmed by a secondary care Consultant e.g. Urologist, Paediatrician

Yes No

*If clinician considers need for referral/treatment on clinical grounds outside of these criteria, please refer to the Individual Funding Request policy for further information. This policy does not apply to

Penile malignancy. Use the 2ww cancer referral pathway Traumatic foreskin injury where it cannot be salvaged



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Treatment of benign perianal skin lesions in secondary care



The CCG will only fund surgical treatment of benign skin lesions when the following criteria are met:



There is clinical uncertainty about the benign nature of the skin lesion Yes NoViral warts in immunocompromised patients where underlying malignancy may be masked Yes NoRecommended by GU Med when conservative treatment has failed Yes No

*If clinician considers need for referral/treatment on clinical grounds outside of these criteria, please refer to the Individual Funding Request policy for further information.



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HaemorrhoidectomyInstructions for use:To Referring Clinicians (e.g. GP’s): Please refer to the above policy and complete the following form priorto referral.


The CCG will only fund haemorrhoidectomy when the following criteria are met:

In ordinary circumstances*, referral should not be considered unless the patient meets the following criteria.


Recurrent third or fourth degree haemorrhoids OR Yes NoIrreducible and large haemorrhoids with frequently reoccurring, persistent pain or bleeding OR

Yes No

Failed conservative treatment (including non-operative interventions: rubber band ligation, injection sclerotherapy, infrared coagulation/photocoagulation, bipolar diathermy and direct-current electrotherapy.)

Yes No




71

Surgery for Ingrown ToenailsInstructions for use:To Referring Clinicians (e.g. GP’s): Please refer to the above policy and complete the following form priorto referral.


The CCG will only fund surgery for ingrown when the following criteria are met:

In ordinary circumstances**, referral should not be considered unless the patient meets one of the following criteria.


Patient is in clinical need of surgical removal of ingoing toe nail has been seen by a community podiatrist and has a documented allergic reaction to local anaesthetic preventing treatment in the community and a general anaesthetic will be needed.

Yes No

Patient has infection and/or recurrent inflammation due to ingrown toenail AND has high medical risk*.

Yes No

*Medical risk is determined by the referring clinician - including, but not limited to, vascular disease, neurological disease or diabetes which are categorised as having high medical need due to the risk of neuropathic complications.

**If clinician considers need for referral/treatment on clinical grounds outside of these criteria, please refer to the Individual Funding Request policy for further information.



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Hallux Valgus SurgeryInstructions for use:To Referring Clinicians (e.g. GP’s): Please refer to the above policy and complete the following form priorto referral.


The CCG will only fund hallux valgus surgery when the following criteria are met:

This procedure is not funded for cosmetic reasons or for asymptomatic or mild symptomatic hallux valgus.

In ordinary circumstances*, referral should not be considered unless the patient meets one of the following criteria.


Significant and persistent pain when walking AND conservative measures tried for at least six months (e.g. Toe spacers, bunion pads, medication or altered footwear) do not provide symptomatic relief OR

Yes No

Ulcer development at the site of the bunion or the sole of the foot OR Yes NoEvidence of severe deformity (overriding toes) OR Yes NoPhysical examination and X-ray show degenerative changes in the 1st metatarsophalangeal joint, increased intermetatarsal angle and/or valgus deformity >15 degrees

Yes No




73

Meibomian cyst/chalazionInstructions for use:To Referring Clinicians (e.g. GP’s): Please refer to the above policy and complete the following form priorto referral.


The CCG will only fund management of Meibomian cyst when the following criteria are met :

In ordinary circumstances*, referral should not be considered unless the patient meets two or more of the following criteria


Conservative treatment has been tried for at least 3 months AND Yes NoInterferes with vision OR Yes NoIs causing persistent inflammation and pain Yes No

* If the patient does not fulfil these criteria but the clinician feels there are exceptional circumstances please refer to the Individual funding request policy for further information.

A meibomian cyst/chalazion that keeps coming back should be biopsied to rule out malignancy. Use the appropriate referral route for suspected malignancy in this case.



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Upper Eyelid Blepharoplasty



The CCG will only fund management of blepharoplasty when the following criteria are met :

In ordinary circumstances*, referral should not be considered unless the patient meets one or more of the following criteria


Does the patient complain of symptoms of blepharospasm or significant dermatitis on the upper eyelid caused by redundant tissue?

Yes No

Did the patient develop symptoms following skin grafting for eyelid reconstruction? Yes NoDid the patient develop symptoms following surgery for ptosis? Yes No

* If the patient does not fulfil these criteria but the clinician feels there are exceptional circumstances please refer to the Individual funding request policy for further information.

If the above criteria are not met, does the patient meet ALL of the following exceptions:–

Is there documentation that the patient complains of interference with vision or visual field related activities such as difficulty reading or driving due to upper eye lid skin drooping, looking through the eyelids or seeing the upper eye lid skin AND

Yes No

Is there redundant skin overhanging the upper eye lid margin and resting on the eyelashes when gazing straight ahead AND

Yes No

Evidence from visual field testing that eyelids impinge on visual fields reducing field to 120° laterally and/or 20° or less superiorly

Yes No



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Arthroscopic Subacromial Decompression of the Shoulder (ASAD)Instructions for use:To Referring Clinicians (e.g. GP’s): Please refer to the above policy and complete the following form priorto referral.


The CCG will only fund ASAD when the following criteria are met:

In ordinary circumstances*, referral should not be considered unless the patient meets ALL of the following criteria.


Patient has had symptoms for at least 3 months from the start of treatment AND Yes NoSymptoms are intrusive and debilitating (for example waking several times a night, pain when putting on a coat) AND

Yes No

Patient has been compliant with conservative intervention (education, rest, NSAIDs, simple analgesia, appropriate physiotherapy) for at least 6 weeks AND

Yes No

Patient has initially responded positively to a steroid injection but symptoms have returned despite compliance with conservative management AND

Yes No

Referral is at least 8 weeks following steroid injection AND Yes NoPatient confirms that they wish to discuss surgical treatment options Yes No

*If clinician considers need for referral/treatment on clinical grounds outside of these criteria, please refer to the CCG Individual Funding Request policy for further information.

Primary Subacromial decompression in isolation is not normally funded unless the patient has a massive subacromial spur scoring the muscle and may otherwise require a cuff repair.



76

17. Patient Information Sheet

Patient information sheet Procedures of limited clinical value and clinical thresholds

How do we choose the best treatment for your health problems?

By using a combination of the evidence provided by national clinical thresholds and procedures of limited clinical value South Yorkshire & Bassetlaw CCG are able to choose the best treatment for your health problems. This leaflet briefly explains where those ideas came from and how they are used.

What is a procedure of limited clinical value?

Procedures of limited clinical value are procedures which medical experts have suggested have only limited or temporary benefit and which are not felt to be necessary to maintain good health

What is a clinical threshold?

Clinical thresholds are a predetermined set of criteria that must be met before some procedures are considered. The threshold may be such that medication would deal with the problem. Surgery should be a last resort for a number of conditions and should not take place before considering and trying other non-surgical, reasonable options.

Your GP will look for alternatives to surgery for certain procedures where clinical thresholds apply.

Assessing what people in South Yorkshire & Bassetlaw need

Our aim is to provide both value for money alongside quality services based on the whole population of SY&B. We aim to do this in a way that is fair so that different people with equal need have equal opportunity to access services.

What is SY&B CCG’s approach to procedures of limited clinical value?

Some treatments will only be considered if specific predetermined and evidence based criteria have been met; these are the clinical thresholds for treatment as set out in SY&B CCG’s Commissioning for Outcomes policy.

This approach is not new. These clinical thresholds are already in place at many other CCGs.

Clinical thresholds apply to the following:

Examples

Research has shown that around 80% of individuals with carpal tunnel syndrome initially respond to non-surgical treatment, especially among young people or pregnant women

Gallstones are often seen on scans but do not cause any symptoms or only mild symptoms which can be controlled by diet.

Research has shown that obese patients suffer significant complications following hip/knee surgery, such as joint infections and poor healing.

Medical treatment for heavy menstrual bleeding is very successful and in many circumstances prevents the need for hysterectomy and complications of surgery.

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Benign Skin Lesions Carpal Tunnel Surgery Cataract Surgery Cholecystectomy (Gall Bladder surgery) Dupuytren’s Disease Ganglion Surgery Grommets Hernia Repair Hip and Knee Replacement Hysterectomy for Heavy Menstrual Bleeding Tonsillectomy Trigger Finger Varicose Vein Surgery Upper Eye Lid Blepharoplasty Chalazion Surgery for ingrown Toe Nail in Secondary care Bunions Haemorrhoidectomy Benign perianal skin lesions Male Circumcision

What are the implications for you?

This may mean that your doctor is not able to offer you a certain treatment because it would not be funded by the local NHS. Your doctor has to observe the policy because it is the policy of the local NHS, and is the best way to ensure that local NHS funds are spent on the things that will bring greatest overall health benefit to local people.

In some circumstances, your GP, Consultant or NHS clinician may think you have exceptional clinical circumstances and may benefit from a treatment which is not routinely provided. Requests for such treatments must be made through an Individual Funding Request (IFR) by your clinician. This request will then be considered and approved or rejected by an independent panel.

Where you do not meet the criteria for referral you should see your GP or other appropriate health care professional should your condition change. Likewise if you are on a pathway for elective care, you should request a clinical review if your condition changes.

If you are considered to be a vulnerable patient (those with mental health issues, learning disability or cognitive impairment) you should be clinically assessed and given the opportunity to improve your lifestyle by referral for appropriate interventions.

Further information in respect of the Commissioning for Outcome Policy can be found on the internet at: https://www.healthandcaretogethersyb.co.uk/

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https://www.healthandcaretogethersyb.co.uk/

How can you raise a concern/complaint about this policy?

Information regarding how to raise concerns or make a complaint to your CCG can be found at:

BARNSLEY

Write to: Quality Team, Barnsley CCG’ Hillder House, 49 – 51 Gawber Road, Barnsley, S75 2PY or alternatively you can telephone: 01226 433716 or Email: [email protected]

For further advice you can also contact Healthwatch at: The Core, County Way, Barnsley, S70 2JW or Tel: 01226320106

BASSETLAW

Write to: Complaints Department, Retford Hospital, North Road, Retford, Notts, DN22 7XFor alternatively you can telephone: 01777 863321or Email: [email protected]

For further advice you can also contact Healthwatch at; Unit 2, Byron Business Centre, Duke St, Hucknall, Notts, NG15 7HP or Tel: 01159635179

DONCASTER

Write to: Patient Experience Manager, Doncaster CCG, Sovereign House, Heaven’s Walk, Doncaster, DN4 5HZOr alternatively you can telephone 01302 566228Or Email: [email protected]

For further advice you can also contact Healthwatch at: 3 Cavendish Court, South Parade, Doncaster, DN1 2JD or Tel: 0808 8010391

ROTHERHAM

http://www.rotherhamccg.nhs.uk/concerns-and-complaints.htmWrite to: Rotherham CCG, Oak House, Moorhead Way, Rotherham, South Yorkshire S66 1YY or alternatively you can telephone: 01709 302108 or Email: [email protected]

For further advice you can also contact Healthwatch at: 22-30 High St, Rotherham S60 1PP or Tel: 01709717130

SHEFFIELD

http://www.sheffieldccg.nhs.uk/about-us/contact-us.htmWrite to: Complaints Team, NHS Sheffield CCG, 722 Prince of Wales Road, Sheffield, S9 4EUor alternatively you can telephone (0114) 305 1000or Email: [email protected]

For further advice you can also contact Healthwatch at: The Circle, 33 Rockingham Lane, Sheffield, S1 4FW or Tel: 01142536688

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http://www.sheffieldccg.nhs.uk/about-us/contact-us.htm


http://www.rotherhamccg.nhs.uk/concerns-and-complaints.htm



18. Table 2 OPSC Codes

Procedure Primary Procedure CodesFirst Secondary Procedure Codes

Second Secondary Procedure Codes

Primary Diagnosis Codes Other Criteria

Carpal Tunnel Syndrome A651, A659 G560

Hip and Knee Replacement for Osteoarthritis (Hips)W371, W378, W379, W381, W388, W389, W391, W398, W399, W931, W938, W939, W941, W948, W949, W951, W958, W959

M15, M16, M17

Hip and Knee Replacement for Osteoarthritis (Knees)W401, W408, W409, W411, W418, W419, W421, W428, W429, O181, O188, O189

M15, M16, M17

Asymptomatic gallstonesJ181, J182, J183, J184, J185, J188, J189, J211, J212, J213, J218, J219

K802, K805

Cataract SurgeryC711, C712, C713, C718, C719, C721, C722, C723, C728, C729, C741, C742, C743, C748, C749, C751, C752, C753, C754, C758, C759

1) T191, T192, T198, T199, 1) <> N132 1) K402, K409, K439, K469

1) Age >= 18

2) T20, T21, T25, T26, T27 2) NOT IN (G693, H111, G762, H175)

2) K402, K409, K439, K469

2) Age >= 18

3) T24 3) K429 3) Age >= 18

1) T521, T522, T525, T526, T541 1) M720

2) T528, T529, T548, T549, T558, T559, T561, T562, T571, T574, T578, T579

2) Z894 2) M720

GanglionT591, T592, T593, T594, T598, T599, T601, T602, T603, T604, T608, T609, T611, T613, T618, T619

Trigger FingerT691, T692, T698, T699, T701, T702, T718, T719, T723, T728, T729

M653

Asymptomatic inguinal hernias in adults

Dupuytren’s Contracture

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Adenoidectomy E201, E204

Anal Skin Tags H482

1) X851 1) G80 or R61

2) Any 2) X851 2) G80 or R61

3) X851 3) Any3) 1st Secondary Diagnosis G80 or R61

4) Any 4) X851 4) Any4) 1st Secondary Diagnosis G80 or R61

BunionsW791, W792, W799, W151, W152, W153, W154, W155, W156, W158, W159, W591, W592, W593, W594, W595, W596, W597, W598, W599

M201

Chalazion Is not blank H001

Dilatation & Curettage Q103, Q108, Q109 N920, N921, N922, N924

Eyelid Surgery (excluding Chalazion)C121, C122, C123, C124, C125, C126, C128, C129, C131, C132, C133, C134, C138, C139, C161, C162, C163, C164, C165, C168, C169

<> H001

HaemorrhoidectomyH511, H512, H513, H518, H519, H521, H522, H523, H528, H529, H531, H532, H533, H538, H539

1) S641, S642, S681, S682, S683, S701 1) Z906, Z907, Z506

2) S641, S642, S681, S682, S683, S7012) S641, S642, S681, S682, S683, S701

2) Z906, Z907, Z506

Male Circumcision N303

Shoulder Arthroscopy Is not blank M750, M751, M754

Vasectomy N171

Ingrowing toe nail

Botulinum Toxin Type A (Botox) for Spasticity or Hyperhidrosis

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1) S063, S064, S065, S081, S082, S083, S088, S089, S101, S102, S103, S104, S105, S108, S109, S111, S112, S113, S114, S115, S118, S119

1) Any

2) Is not blank 2) D17, L82

Hysterectomy Q072, Q074, Q075, Q082 N920, N921, N922, N924

Hysteroscopy Q181, Q188, Q189 N920, N921, N922, N924

Myringotomy / Grommets D151, D153

Tonsillectomy F341, F342, F343, F344, F349

Varicose Veins

L841, L842, L843, L844, L845, L846, L848, L849, L851, L852, L853, L858, L859, L861, L862, L868, L869, L871, L872, L873, L874, L875, L876, L877, L878, L879, L881, L882, L883, L888, L889

Benign Skin Lesions

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Appendix 2

19. Definitions

Definition of Procedures of Limited Clinical ValueProcedures of limited clinical value are those that deliver a relatively poor output/outcome to the population. This schedule sets out those procedures of limited clinical value that are not routinely commissioned or only commissioned when certain criteria are met.

Definition of Clinical ThresholdsClinical thresholds are a predetermined set of criteria that must be met before some procedures are considered. The threshold may be such that medication would deal with the problem. Surgery should be a last resort for a number of conditions and should not take place before considering and trying other non-surgical, reasonable options.

Definition of CommissioningAssessing local needs, agreeing priorities and strategies, and then buying services on behalf of our population from a range of providers whilst constantly responding and adapting to changing local circumstances.

Definition of Individual Funding RequestAn individual funding request is where prior approval for a patient’s treatment is required due to that treatment or symptom criteria being outside of our approved commissioning policies and in such cases exceptionality will need to be proven.

Definition of ExceptionalityIn order to demonstrate exceptionality the patient

21. Must be significantly different to the population of interest (i.e. patients with pulmonary hypertension and/or the subpopulation), and,

22. Be more likely to benefit from this intervention than might be expected than other patients with the condition

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Appendix 3

20. South Yorkshire and Bassetlaw Individual Funding Request Policies

Barnsley CCG - Individual Funding Requests Policy

Basssetlaw CCG - Individual Funding Requests Policy

Doncaster CCG - Individual Funding Request Policy

Rotherham CCG - Individual Funding Request Policy

Sheffield CCG - Individual Funding Request Policy

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